Health inspection·December 8, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), that addressed Resident 1's history of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/21/2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS- an assessment and screening tool) dated 8/7/2025, the MDS indicated Resident 1's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS indicated that Resident 1 required setup or clean-up assistance with eating and partial/moderate assistance with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 1's Trauma Informed Care Screener (a tool used by professionals to identify history of traumatic exposure and assess the severity of potential trauma-related symptoms) dated 5/13/2025 timed at 11:47 a.m., the Trauma Informed Care Screener indicated Resident 1 had a positive trauma screen.During a review of Resident 1's Care Plan (CP) Report, a CP initiated on 5/14/2025 indicated Resident 1 has actual or suspected history of person trauma related to: Resident 1 stated that she was a victim of an attempted assault when she was in her 20's.During an interview on 10/21/2025 at 11:45 a.m., in Resident 1's room, with Resident 1, Resident 1 stated that she has PTSD from an incident with a man back in her 20s and the staff in the facility are aware of it. During a review of Resident 1's Psychiatric Note dated 6/10/2025, the Psychiatric Note indicated Resident 1 reported that she has been having PTSD related anxiety. The Psychiatric Note indicated a diagnosis of PTSD by history.During a concurrent interview and record review on 10/21/2025 at 1:33 p.m. with Assistant Director of Nursing 1 (ADON 1), ADON 1 reviewed Resident 1's care plans were reviewed. ADON 1 stated that Resident 1 did not have a care plan specific for PTSD. ADON 1 stated that Resident 1 should have had a specific care plan that addressed PTSD so that specific interventions could have been in place for Resident 1 such as referring Resident 1 to a female psychologist so Resident 1 can be comfortable in expressing herself. During a review of the facility's policy and procedure (P&P) titled Care planning-Resident Participation, with review date 4/24/2025, the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Page 1 of 3 056124 056124 12/08/2025 Tarzana Health and Rehabilitation Center 5650 Reseda Blvd Tarzana, CA 91356

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on interview and record review, the facility failed to provide resident centered behavioral services for one of three sampled residents (Resident 1), who has a history of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).This deficient practice had the potential to result in Resident 1 not receiving the appropriate treatment and services to correct the assessed behavior or to attain the highest practicable mental and psychosocial well-being.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/21/2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS- an assessment and screening tool) dated 8/7/2025, the MDS indicated Resident 1's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS indicated that Resident 1 required setup or clean-up assistance with eating and partial/moderate assistance with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 1's Trauma Informed Care Screener (a tool used by professionals to identify history of traumatic exposure and assess the severity of potential trauma-related symptoms) dated 5/13/2025 timed at 11:47 a.m., the Trauma Informed Care Screener indicated Resident 1 had a positive trauma screen.During a review of Resident 1's Care Plan (CP) Report, a CP initiated on 5/14/2025 indicated Resident 1 has actual or suspected history of person trauma related to: Resident 1 stated that she was a victim of an attempted assault when she was in her 20's.During an interview on 10/21/2025 at 11:20 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that she was aware that Resident 1 has PTSD because Resident 1 told her. LVN 1 stated is not aware of any behavioral health services for Resident 1's PTSD. During an interview on 10/21/2025 at 11:45 a.m., in Resident 1's room, with Resident 1, Resident 1 stated that she has PTSD from an incident with a man back in her 20s and the staff in the facility are aware of it. Resident 1 stated that the facility is not providing any treatment to help with her PTSD.During a review of Resident 1's Psychiatric Note dated 6/10/2025, the Psychiatric Note indicated Resident 1 reported that she has been having PTSD related anxiety. The Psychiatric Note indicated a diagnosis of PTSD by history.During an interview on 10/21/2025 at 2:18 p.m. with the Director of Nursing (DON), the DON stated that the facility is doing the best they can to provide care to Resident 1. The DON stated that she has talked to Resident 1 to check up on her (Resident 1). The DON stated that no additional behavioral health services have been provided to Resident 1 to address her PTSD other than seeing a psychiatrist. During an interview on 10/21/2025 at 3:17 pm with Assistant Director of Nursing 1 (ADON 1), ADON 1 stated no behavioral health services related to PTSD have been provided to Resident 1. ADON 1 stated that Resident 1 seeing a psychiatrist alone is not sufficient and the facility should have provided additional interventions to address Resident 1's PTSD. Interventions such as additional services and or assessments to identify Resident 1's triggers so that staff could prevent situations that might lead to behavioral responses. During a review of the facility's policy and procedure titled Behavioral Health Services, review date 4/24/2025, the policy and procedure indicated it is the policy of this facility to ensure all the residents received necessary behavioral health services to assist in reaching and maintaining their highest level of mental and psychosocial functioning. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment 056124 Page 2 of 3 056124 12/08/2025 Tarzana Health and Rehabilitation Center 5650 Reseda Blvd Tarzana, CA 91356

F 0742 Level of Harm - Minimal harm or potential for actual harm difficulty, and trauma or post-traumatic stress disorders. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, dependence choice, and safety. Behavioral health care and services shall be provided in an environment that is conductive to mental and psychosocial well-being. Residents Affected - Few 056124 Page 3 of 3