Inspection visit
Health inspection
31 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 31 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a
review of Resident 27's admission record, the admission record indicated the facility admitted the resident
on 9/20/2023, with diagnoses including multiple sclerosis (a chronic disease that damaged the central
nervous system), type two(2) diabetes mellitus (a long-term medical condition in which the body does not
use insulin [a hormone that lowers the level of sugar in the blood] properly) and dementia (impaired ability
to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening
tool), dated 4/4/2024, the MDS indicated the resident was totally dependent on staff with all activities of
daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The
resident had severe cognitive impairment (problems with the ability to think, learn, remember, use
judgement, and make decisions).
During a review of Resident 27's Care Plan (a document that outlines the actions and interventions needed
to address a resident's health and care needs) revised 1/14/2024, the care plan indicated that the resident
has self-care deficits due to cognitive deficit and poor safety awareness. The care plan indicated an
intervention to provide a safe environment.
During an observation on 5/5/2024, at 1:51 p.m., inside Resident 27's room, there was a broken wall
molding, with a piece missing behind the resident's bed.
During a concurrent observation and interview on 5/6/2025 at 3:50 p.m., with the Director of Nursing (DON)
inside Resident 27's room, the DON confirmed that the wall molding behind the resident's bed is broken,
with a piece missing. The DON stated the staff should have reported the broken molding to the
Maintenance Department. The DON stated the Maintenance Department is responsible for making sure
that the wall molding in the room is not damaged. The DON stated she will report the issue to the
Maintenance Department for repairs. The DON stated not reporting the broken wall molding to the
Maintenance Department placed Resident 27 at risk for injuries and accidents.
During concurrent observation and interview with the MD and Administrator on 5/6/2025 at 3:55p.m. in
Resident 27's room, the Administrator concurred that the wall molding behind the resident's bed was
broken, with a piece missing. The MD stated that he was responsible for ensuring that any damaged
moldings were repaired.
During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, last reviewed
7/16/2024, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike and
encouraged to use their personal belongings to the extent possible.
(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 85
Event ID:
056149
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Based on observation, interview, and record review, the facility failed to provide a homelike environment for
four of five sampled residents reviewed under the environment task by failing to:
1.Repair or replace ripped and gouged bed rail padding for Residents 182, 642, and 643.
This deficient practice placed Residents 182, 642, and 643 at risk to experience an unsanitary and
uncomfortable environment.
2.Ensure the molding on the wall behind Resident 27's bed was repaired.
This deficient practice has the potential to make residents feel uncomfortable, place residents at higher risk
for accidents, and negatively affect the residents' quality of life.
Findings:
1. During a review of Resident 182's admission Record, the admission Record indicated the facility
originally admitted the resident on 3/29/2025 and readmitted the resident on 4/29/2025 with diagnoses
including but not limited to cerebral infarction (an obstruction of blood flow in the brain that leads to tissue
damage) and acute respiratory failure (a condition where the lungs cannot release enough oxygen into the
blood).
During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025,
the MDS indicated Resident 182 had severely impaired cognitive skills (problems with the ability to think,
learn, and remember clearly) for daily decision making and required total assistance from staff with
activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 182's Physicians Orders, the Physicians Orders indicated an order for padded
siderails to decrease potential injury dated 4/30/2025.
During a review of Resident 182's care plan titled Resident is on Padded siderails, dated 3/30/2025, the
care plan indicated the resident needs padded bed rails to prevent or reduce incidences of injuries.
During a review of Resident 642's admission Record, the admission Record indicated the facility admitted
the resident on 5/1/2025 with diagnoses including but not limited to acute respiratory failure and
intracerebral hemorrhage (bleeding inside the brain tissue).
During a review of Resident 642's History and Physical, dated 5/3/2025, the History and Physical indicated
Resident 642 was not alert or oriented (a person's awareness of their surroundings, including who they are,
where they are, and what time it is) and was unable to move any extremities.
During a review of Resident 642's Physicians Orders, the Physicians Orders indicated an order for padded
siderails to decrease potential injury dated 5/5/2025.
During a review of Resident 642's care plan titled (Resident 642's name) is on low bed, floor mat and
padded siderails ., dated 4/11/2025, the care plan indicated the goal was to prevent or reduce incidences of
injuries.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 2 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of Resident 643's admission Record, the admission Record indicated the facility admitted
the resident on 4/10/2025 diagnoses including but not limited to cerebral infarction and acute respiratory
failure.
During a review of Resident 643's MDS, dated [DATE], the MDS indicated Resident 643 had severely
impaired cognitive skills for daily decision making and required total assistance from staff with ADLs.
During a review of Resident 643's Physicians Orders, the Physicians Orders indicated an order for padded
siderails to decrease potential injury dated 4/12/2025.
During a review of Resident 643's care plan titled .Padded side rails when in bed to decrease potential
injury, dated 4/11/2025, the care plan indicated the goal was to prevent or reduce incidences of injuries.
During a concurrent observation and interview on 5/8/2025 at 10:51 a.m. with the Subacute Director (SD),
Resident 643, 642, and 182's bed rails were observed to be covered with black foam padding in poor repair.
The SD stated they change the bed rail padding regularly but do not have a set schedule. The black foam
padding on Resident 643's right upper and lower bedrails were observed to have several cracks and
gouges exposing porous (has many holes, so liquid or air can pass through) foam surfaces. The black foam
padding on Resident 642's right upper bed rail was observed to have a large rip exposing porous foam
surfaces. The SD stated the padding on Resident 642's right upper bedrail should be replaced due to the
rip. The black foam padding covering the left upper bedrail on Resident 182's bed had a large rip which
exposed the bed rail and multiple gouges exposing porous foam surfaces. The SD stated the padding
should be replaced due to the rip and because it exposes the bed rail.
During a concurrent interview and record review on 5/8/2025 at 2:39 p.m. with the Director of Nursing
(DON), the DON stated if the bed rail is exposed the resident could potentially be injured. The DON stated
Resident 643, 642 and 182's ripped and gouged bed rail paddings were not in good repair and could
potentially harbor bacteria. The DON stated all rooms should have equipment in good repair for safety
purposes.
During a review of the facility's policy and procedure (P&P) titled Homelike Environment, last reviewed
7/16/2024, the P&P indicated residents are to be provided with a safe, clean, comfortable, environment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 3 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure residents were free from any
physical restraints (any manual method, physical or mechanical device, material or equipment that is
attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of
movement or normal access to one's body) for two of three sampled residents (Resident 149 and Resident
183) by failing to:
Residents Affected - Some
1. Perform a bed rail/side rail (a safety device that can be installed on the side of a bed to help people get in
and out of bed, turn in bed, and prevent falls) assessment prior to putting up the residents' lower side rails.
2. Obtain a physician's order on the use of bed rail/side rail.
This deficient practicse had the potential to result in the restriction of residents' freedom of movement and
physical harm from entrapment.
Findings:
a. During a review of Resident 149's admission Record, the admission Record indicated that the facility
admitted Resident 149 on 1/14/2025 with diagnoses including but not limited to metabolic encephalopathy
(a condition that affects brain function due to an imbalance in the body's metabolism [chemical processes
that convert food into energy]), acute respiratory failure with hypoxia (a sudden, life-threatening condition
where the lungs struggle to exchange enough oxygen and carbon dioxide in the blood), and congestive
heart failure (a condition where the heart muscle is weakened and cannot pump enough blood to meet the
body's needs), and need for assistance with personal care.
During a review of Resident 149's History and Physical (H&P), dated 5/8/2025, the H&P indicated Resident
149 did have the capacity to understand and make decisions.
During a review of Resident 149's Minimum Data Set (MDS - a federally mandated resident assessment
tool), dated 4/29/2025, the MDS indicated that the resident can understand others and make himself
understood. The MDS indicated that Resident 149 was dependent on staff with activities of daily living
(ADLs - basic tasks that must be accomplished every day for an individual to thrive) such as eating,
hygiene. dressing, toileting and bathing. The MDS further indicated the resident was dependent on staff to
roll left or right and movements such as sit to lying, sit to stand and walking were not attempted.
During a review of Resident 149's Informed Consent dated 3/3/2025, the informed consent indicated a
treatment of bilateral upper half siderails for mobility, ADL's (activities of daily living - such as bathing,
dressing and toileting a person performs daily) and changing positions.
During an observation on 5/5/2025 at 9:52 am in Resident 149's room, Resident 149 was lying in bed with
both upper and one lower side rails up.
During concurrent observation and interview on 5/5/2025 at 9:59 am, in Resident 149's room with the
Assistant Director of Nursing (ADON), the ADON pointed to the lower side rails and stated that the lower
side rail must not be up without a signed consent, and it could be considered a restraint
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 4 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0604
because the resident can get stuck in or between the upper and lower rails.
Level of Harm - Minimal harm
or potential for actual harm
During a concurrent interview and record review on 5/8/2025 at 2:33 pm with the Director of Nursing
(DON), the DON stated that according to the facility's policy, the use of bed rails is prohibited unless the
criteria for use had been met including the assessment of the resident and a signed informed consent. The
DON further stated Resident 149 had a consent for upper side rails only and his lower side rails should
never have been up because the resident could have been trapped.
Residents Affected - Some
During a review of the Policy and Procedure (P&P) named Bed safety and Bed Rails, last reviewed on
7/16/2024, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have
been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and
informed consent. The P&P further indicated the resident assessment determines potential risks such as
accidents associated with the resident attempting to climb over, around, between or throughout the rails or
their body could be caught between the rails and mattress.
During a review of the P&P named Use of Restraints, last reviewed on 7/16/2024, the P&P stated restraints
shall only be used for the safety and well-being of residents. The P&P defined restraints as any manual
method or a physical or mechanical device, material or equipment attached to or adjacent to the resident's
body that the individual cannot remove easily, which restricts freedom of movement or restricts normal
access to one's body.
b. During a review of Resident 183's admission Record, the Administration Record indicated that the facility
admitted Resident 183 on 3/31/2025 with diagnoses including but not limited to adult failure to thrive (when
an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than
normal), dysphagia (difficulty swallowing), need for assistance with personal care, stiffness on left ankle,
and major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest in
activities previously enjoyed).
During a review of Resident 183's History and Physical (H&P), dated 4/2/2025, the H&P indicated Resident
183 did have the capacity to understand and make decisions.
During a review of Resident 183's Minimum Data Set (MDS - a federally mandated resident assessment
tool), dated 4/12/2025, the MDS indicated that the resident can understand others and make herself
understood. The MDS further indicated Resident 183 required substantial assistance from staff for activities
such as toileting, hygiene, sit to stand, toilet transfer and walking.
During a review of Resident 183's Physician's Order dated 3/31/3035, the order indicated an order for
bilateral upper half side rails when in bed for safety and protection.
During a review of Resident 183's Informed Consent dated 3/31/2025, the informed consent indicated a
treatment of bilateral upper half siderails for mobility, ADL's and changing positions.
During an observation on 5/5/2025 at 10:11 am in Resident 183's room, Resident 183 was lying in bed with
both upper and one lower side rails up.
During concurrent observation and interview on 5/5/2025 at 10:15 am, in Resident 183's room with the
Assistant Director of Staff Development (ADSD), the ADSD stated the lower side rail should not be up and
could be dangerous because the resident could get a body part stuck in it.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 5 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0604
Level of Harm - Minimal harm
or potential for actual harm
During an interview and record review on 5/8/2025 at 2:37 pm with the Director of Nursing (DON), the DON
stated according to the facility's policy, the use of bed rails is prohibited unless the criteria for use had been
met including the assessment of the resident and a signed informed consent. The DON further stated
Resident 183 had a consent for upper side rails only and his lower side rails should never have been up
because the resident could have been trapped.
Residents Affected - Some
During a review of the Policy and Procedure (P&P) named Bed safety and Bed Rails, last reviewed on
7/16/2024, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have
been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and
informed consent. The P&P further indicated the resident assessment determines potential risks such as
accidents associated with the resident attempting to climb over, around, between or throughout the rails or
their body could be caught between the rails and mattress.
During a review of the P&P named Use of Restraints, last reviewed on 7/16/2024, the P&P stated restraints
shall only be used for the safety and well-being of residents. The P&P defined restraints as any manual
method or a physical or mechanical device, material or equipment attached to or adjacent to the resident's
body that the individual cannot remove easily, which restricts freedom of movement or restricts normal
access to one's body.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 6 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to complete a comprehensive Minimum Data Set
([MDS] a federally mandated resident assessment tool) for one of 38 sampled residents (Resident 690)
after admission on [DATE]. This failure had the potential to prevent Resident 690 from receiving services to
achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent
handle at the top and long shaft that ends in a single tip used to provide support while walking) to return
home.
Findings:
During a review of Resident 690's admission Record, the admission Record indicated the facility admitted
Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges
(three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic
intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop
(condition where the individual experiences difficulty or inability to lift their foot or toes) of both feet, and
reduced mobility (ability to move).
During a review of Resident 690's admission Minimum Data Set ([MDS] a federally mandated resident
assessment tool), dated 4/29/2025, the admission MDS indicated Resident 690 had clear speech,
expressed ideas and wants, clearly understood verbal content, and had intact cognition (clear ability to
think, understand, learn, and remember). The MDS did not include the signature of the Registered Nurse
(RN) Assessment Coordinator verifying the completion of Resident 690's admission MDS.
During a concurrent observation and interview on 5/6/2025 at 11:27 a.m. with Resident 690 in the
resident's room, Resident 690 was awake, alert, and spoke with clear, fluent speech while lying in bed with
the head-of-bed elevated. Resident 690 stated the facility was aware of Resident 690's complaints
regarding not receiving rehabilitation (therapy given to restore an individual back to their highest possible
level of physical, mental, and psychosocial well-being) services. Resident 690 stated she underwent brain
surgery three times and walked with a SPC due to left leg weakness after the second brain surgery and
prior to the third surgery in 2/2025. Resident 690 stated the desire to return home after receiving therapy.
During a concurrent interview and record review on 5/8/2025 at 10:19 a.m. with the MDS Coordinator RN
(MDSC), Resident 690's admission MDS, dated [DATE], was reviewed. The MDSC stated the MDS (in
general) was a thorough assessment to ensure the residents were receiving appropriate care and meeting
their goals. The MDSC stated the Admisison MDS should be completed by the 14th day of admission. The
MDSC stated the facility admitted Resident 690 on 4/18/2025 and should have completed the admission
MDS on 4/29/2025. The MDSC stated Resident 690's admission MDS was not completed since all the
departments did not complete their assigned section of the MDS. The MDSC stated the facility could fail to
address an area of Resident 690's care since the admission MDS was not completed.
During a review of page 2-17 of the Resident Assessment Instrument (RAI) Manual, revised 10/1/2023, the
RAI Manual indicated the admission MDS should be completed no later than the 14th calendar day of the
resident's admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 7 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized
assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services
(CMS) system for one (1) out of one (1) sampled residents (Resident 35).
Residents Affected - Few
This deficient practice had the potential to result in delayed services for Resident 35.
Findings:
During a review of the admission record , the admission record indicated Resident 35 was admitted to the
facility on [DATE] and readmitted on [DATE] with diagnosis including type 2diabetes (a long-term medical
condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood]
properly), urinary tract infection (infection in any part of the urinary system), and essential hypertension
(high blood pressure that is not due to another medical condition).
During a review of Resident 35's Record of Death dated [DATE], the record of death indicated that the body
of Resident 35 was released on [DATE].
During a review of the Transfer/ Discharge Report, dated [DATE], the Transfer/Discharge Report indicated
that the resident was DNR.
During a review of Resident 35's Discharge Summary Report dated [DATE], the Discharge Summary
Report indicated Resident 35 resident expired on [DATE].
During a review of the Minimum Data Set assessment dated [DATE], (MDS, a standardized assessment
and care screening tool), the MDS indicated Resident 30 had mildly impaired cognition (a slight decline in
mental abilities, memory and completing complex tasks). The MDS indicated Resident 30 required
moderate assistance for all activities of daily living (ADL- basic tasks that must be accomplished every day
for an individual to thrive).
During a concurrent interview and record review on [DATE] at 2:45 p.m., with Minimum Data Set
Coordinator 1 (MDSC 1), Resident 35`s MDS assessments were reviewed. MDSC 1 stated that when a
resident is being discharged from the facility, they (facility) are required to complete an MDS assessment .
MDSC 1 stated, We have 14 days to complete the discharge MDS. MDSC 1 stated Resident 30 was
discharged from the facility on [DATE], however, the MDS for discharge was not completed and not
submitted to Center for Medicaid Services (CMS).
During an interview on [DATE] at 3:15 p.m., with the Director of Nursing (DON) the DON stated the
discharge assessment has to be done and submitted to CMS in 14 days following the resident's discharge,
by the Minimum Data Set Nurse (MDSC). The DON stated the potential outcome of not completing
discharge MDS assessment on time is a delay in care and payment for Resident 30.
During a review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility
Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1 dated [DATE], indicated all Medicare
and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit
required MDS data records to CMS' Internet Quality Improvement and Evaluation System
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 8 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0640
Level of Harm - Minimal harm
or potential for actual harm
(iQIES). Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan
Completion Date. All other MDS assessments must be submitted within 14 days of the MDS completion
date.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 9 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a
review of Resident 163's admission Record, the admission Record indicated that the facility admitted the
resident on 7/20/2024 with a diagnosis of schizophrenia (a mental illness that is characterized by
disturbances in thought).
Residents Affected - Some
During a review of Resident 163's MDS, dated [DATE], the MDS indicated that the resident was in a
persistent vegetative state with no discernible consciousness and was dependent on staff for all activities of
daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).
On 5/7/2025 at 12:40 p.m., during a concurrent interview and record review, reviewed Resident 163's MDS
records with the Minimum Data Set Coordinator (MDSC). A review of the admission MDS, dated [DATE],
Section I - Active Diagnoses indicated that the resident did not have an active diagnosis of schizophrenia. A
review of the Quarterly MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did
have an active diagnosis of schizophrenia. A review of the Quarterly MDS, dated [DATE], Section I - Active
Diagnoses indicated that the resident did have an active diagnosis of schizophrenia. Reviewed the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 - a comprehensive guide used
by mental health professionals to diagnose and classify mental disorders) Criteria for Schizophrenia with
the MDSC, which indicated that two or more symptoms or behaviors must be present for a significant
portion of time during a 1-month period. The MDSC stated that the resident's admission MDS, dated
[DATE], was actually coded correctly because, according to their Centers for Medicare & Medicaid Services
(CMS - a federal agency within the Department of Health and Human Services [DHHS]) audit, the resident
must have been diagnosed with schizophrenia earlier in life, exhibited at least two behaviors as indicated
on the DSM-5 Criteria for Schizophrenia, and have psychiatric progress notes explaining the resident's
diagnosis. The MDSC stated that the following Quarterly MDSs should not have been coded for an active
diagnosis of schizophrenia because the resident was in a vegetative state and, therefore, did not meet the
DSM-5 criteria for a diagnosis of schizophrenia. In addition, the MDSC stated that the resident's diagnosis
of schizophrenia was carried over from the hospital, and the facility did not have the documentation to show
why the resident was diagnosed with schizophrenia. Reviewed the residents General Acute Care Hospital
(GACH) History and Physical (H&P - a comprehensive assessment conducted by a healthcare provider to
evaluate a patient's overall health) with the MDSC. The MDSC stated that the only indication from the
GACH records that the resident had schizophrenia was from a family interview. The MDSC stated that the
staff who completed the Quarterly MDSs should have double checked for the accuracy of information.
On 5/8/2025 at 11:18 a.m., during an interview, with the Director of Nursing (DON), the DON stated that the
purpose of the MDS was to comprehensively assess residents to guide their plan of care. The DON stated
it was important for the MDS to be accurate because it directed what interventions residents may or may
not need. The DON stated that if residents' MDS were coded incorrectly, then providers may be giving
incorrect care, which can negatively affect the resident.
During a review of the facility's policy and procedure titled, Resident Assessments, last reviewed on
7/16/2024, the policy and procedure indicated that all persons who have completed any portion of the MDS
resident assessment form sign the document attesting to the accuracy of information.
Based on observation, interview and record review the facility failed to provide an assessment that
accurately reflects the residents' status for two of two residents (Resident 5 and Resident 163) by
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 10 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0641
failing to:
Level of Harm - Minimal harm
or potential for actual harm
a. Accurately assess and document Resident 5's hearing assessment on the Social Services Hearing
Assessment Form on 12/12/24, accurately code Resident 5's ability to hear in section B of the MDS and
complete a quarterly Social Services Hearing Assessment thereafter for one of one resident (Resident 5)
investigated under the communication/sensory area
Residents Affected - Some
This failure prevented Resident 5 from receiving the services and equipment needed to hear more clearly.
b. Accurately code schizophrenia (a mental illness that is characterized by disturbances in thought) in
Resident 163's Minimum Data Set (MDS - a resident assessment tool).
This deficient practice had the potential to inaccurately depict the resident's needs thus affecting his/her
plan of care.
Findings:
a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted
Resident 5 on 2/28/2024 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by
difficulty in blood sugar control and poor wound healing), heart failure (a condition where the heart muscle
is weakened and cannot pump blood effectively enough to meet the body's need), acute kidney failure (a
sudden and significant loss of kidney [organ that filters blood] function), and depression (persistent feelings
of sadness, hopelessness, and loss of interest in activities previously enjoyed).
During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening
tool), dated 3/12/2025, the MDS indicated Resident 5 has some memory issues but is understood and able
to understand others. The MDS further indicated Resident 5 had adequate (no difficulty in normal
conversation, social interaction, listening to TV) hearing.
During a review of Resident 5's Order Summary Report, the Order Summary Report indicated an active
order dated 2/28/2024, for an audiology (a branch of science dealing with hearing) consult PRN (as
needed) for hearing problems.
During a review of Resident 5's Social Service Assessment (Hearing) dated 12/12/2024, the assessment
indicated Resident 5 has an impaired hearing pattern and hearing appliances and consultation are not
indicated. Further review did not indicate a Social Service Assessment (Hearing) was conducted for the first
quarter of 2025.
During an interview on 5/5/2025 at 10:50 am with Resident 5 in Resident 5's room, Resident 5 stated he
has a hard time hearing and has been waiting for approximately six months for hearing aids. Resident 5
stated about four or five months ago, he went to see the ear doctor but was told because they were late, he
could not be seen. Resident 5 stated, and he was told he would be seen at the facility instead, but no one
has seen him yet. Resident 5 further stated his favorite activity is watching TV, but it was very hard for him
to hear it.
During a concurrent interview and record review on 5/7/2025 at 1:35 pm with the Social Service Director
(SSD), the SSD stated Resident 5 saw the ENT (ear, nose, throat) doctor on 11/26/24 and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 11 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
recommended an audiology exam for hearing aids. The SSD stated Resident 5 had an audiology
appointment on 2/3/2025, but they could not accommodate a gurney and the follow-up audiology
appointment on 2/10/2025 was cancelled because the audiology office could not accommodate a gurney.
The SSD stated the facility did not offer audiology services in-house. The SSD stated the social worker that
completed the Social Service Assessment (Hearing) form on 12/12/2024 no longer works at the facility and
should have checked off a hearing consultation is needed. The SSD stated she should have completed a
Social Service Assessment (Hearing) by March 2025 to ensure Resident 5 received the services he
needed. The SSD further stated six months is too long of a wait for hearing aids and she should have
prioritized him.
During a concurrent interview and record review on 5/8/2025 with the Minimum Data Set Coordinator
(MDSC) at 11:15 am, the MDSC reviewed Resident 5's MDS Section B for hearing dated 3/12/2025 and
stated he should have coded moderate difficulty instead of adequate. The MDSC stated it is important to
have accurate assessment to make sure residents receive the proper care and services.
During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, last reviewed on
7/16/2024, the policy and procedure indicated that all persons who have completed any portion of the MDS
resident assessment form sign the document attesting to the accuracy of information.
During a review of the facility's P&P titled, Hearing Impaired Resident, Care Of, the P&P indicated staff will
assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other
residents and visitors. The P&P indicated the facility does not provide comprehensive audiological
evaluations or devices to assist with hearing and staff will assist the resident (or representative) with
locating available resources, scheduling appointments and arranging transportation to obtain needed
services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 12 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop a complete baseline care plan within 48 hours of a
resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube
inserted into the bladder to drain or collect urine) for one of one sampled resident (Resident 99) reviewed
under catheter care area.
This deficient practice had the potential of Resident 99 to not receive appropriate care and treatment in the
facility.
Findings:
During a review of Resident 99's admission Record (face sheet), the admission Record indicated that the
facility originally admitted the resident on 9/15/2020 and readmitted on [DATE], with diagnoses including
type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor
wound healing), obstructive uropathy (a blockage in the urinary tract that prevents urine from draining
normally), and reflux uropathy (when urine flows backward into the kidneys).
During a review of Resident 99's Minimum Data Set (MDS - a resident assessment tool) dated 4/6/2025,
the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor,
cues/supervision required). The MDS indicated that Resident 99 was dependent on staff for showering and
bathing. The MDS indicated that Resident 99 required staff partial/moderate assistance (helper does less
than half the effort) for toileting hygiene, and upper body dressing. The MDS further indicated that Resident
99 had an indwelling catheter.
During a review of Resident 99's physician Order Summary Report (physician orders) dated 4/25/2025, the
Order Summary Report indicated an order for indwelling catheter due to neurogenic bladder (a problem in
which a person lacks bladder control due to a brain, spinal cord, or nerve condition). The order summary
report indicated to provide indwelling catheter care during every day shift for 30 days.
During a concurrent interview and record review on 5/7/2025 at 8:30 a.m., with the Assistant Director of
Nursing (ADON), Resident 99`s baseline care plan was reviewed. The ADON stated that Resident 99 was
readmitted to the facility on [DATE] with an indwelling catheter. The ADON stated that Resident 99`s
baseline care plan initiated on 1/22/2025, did not indicate that the resident had an indwelling catheter. The
ADON stated that residents` baseline care plans must be completed thoroughly reflecting a problem, initial
care plan outcome, and nursing interventions. The ADON stated that the potential outcome of not
thoroughly completing a resident`s baseline care plan is the inability to meet the resident`s immediate care
needs and lack of care.
During an interview on 5/8/2025 at 3:00 p.m., with the Director of Nursing (DON), the DON stated a
resident`s baseline care plan is required to be completed within 48 hours of the resident`s admission to the
facility. The DON stated upon admission, licensed staff are required to develop a complete and thorough
baseline care plan for each resident indicating a problem and all nursing interventions to be done for that
problem. The DON stated Resident 99`s baseline care plan developed on 1/22/2025 was not completed
thoroughly and it did not indicate anything regarding the resident`s indwelling
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 13 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
catheter. The DON stated the potential outcome is the inability to meet the resident`s immediate care needs
for the indwelling catheter and the delivery of necessary services to the resident.
During review of the facility`s Policy and Procedure (P&P) titled Care Plans-Baseline, last reviewed on
7/16/2024, the P&P indicated that a baseline plan of care to meet the resident`s immediate health and
safety needs is developed for each resident within 48 hours of admission. The baseline care plan includes
instructions needed to provide effective, person-centered care of the resident that meet professional
standards of quality care and must include minimum healthcare information necessary to properly care for
the resident. The resident and/or representative are provided a written summary of the baseline care plan
that includes but is not limited to any services and treatment to be administered by the facility and
personnel acting on behalf of the facility.
Event ID:
Facility ID:
056149
If continuation sheet
Page 14 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
b. During a review of Resident 59's admission Record, the admission Record indicated that the facility
admitted the resident on 2/20/2025 with diagnoses including type 2 diabetes mellitus (DM - a disorder
characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness,
and reduced mobility.
During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025,
the MDS indicated that the resident had moderately impaired cognition (thought processes) and was
dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting
a person performs daily). The MDS also indicated that the resident was at risk of developing pressure
ulcers/injuries and had one or more unhealed pressure ulcers/injuries.
During a review of Resident 59's admission Reassessment, dated 2/21/2025, the reassessment indicated
that the resident had a stage II pressure ulcer/injury on the sacrococcyx.
During a review of Resident 59's physician's order, dated 4/23/2025, the order indicated to cleanse the
resident's sacrococcyx (the area at the base of the spine where the sacrum and coccyx meet) pressure
injury with normal saline (NS - a saltwater solution), pat dry, apply honey to the bed wound, and cover with
a dry dressing (DD) every day shift for 30 days.
On 5/7/2025 at 12:54 p.m., during a concurrent interview and record review, reviewed Resident 59's care
plans (a document that outlines a patient's current health status, diagnoses, treatment goals, and
interventions) with the Minimum Data Set Coordinator (MDSC). The MDSC stated there was no care plan
addressing the resident's pressure ulcer/injury and treatments.
On 5/8/2025 at 11:18 a.m., during an interview with the Director of Nursing (DON), the DON stated that the
purpose of resident care plans was to guide all disciplines in what interventions to provide residents so they
can reach their goals. The DON stated that, in Resident 59's case, the facility should have developed a care
plan to address the resident's pressure ulcer/injury and the prescribed treatments. The DON stated that,
without a care plan, the resident may not receive proper care or treatment, which can cause the wound to
worsen.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered,
last reviewed on 7/16/2024, the policy and procedure indicated that the interdisciplinary team (IDT), in
conjunction with the resident and his/her family or legal representative, develops and implements a
comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care
plan is developed within seven (7) days of the completion of the required MDS assessment (Admission,
Annual, or Significant Change in Status), and no more than 21 days after admission.
The comprehensive, person-centered care plan:
a.
includes measurable objectives and timeframes;
b.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 15 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0656
describes the services that are to be furnished to attain or maintain the resident's highest practicable
physical, mental, and psychosocial well-being;
Level of Harm - Minimal harm
or potential for actual harm
c.
Residents Affected - Some
includes the resident's stated goals upon admission and desired outcomes;
d.
builds on the resident's strengths; and
e.
reflects currently recognized standards of practice for problem areas and conditions.
Based on interview, and record review the facility failed to develop and implement a comprehensive
person-centered care plan (a document that outlines a patient's current health status, diagnoses, treatment
goals, and interventions to two of five sampled residents (Resident 185 and 59) when:
a. A diet order was changed from twice daily pureed (a medical diet where all foods are ground, pressed, or
strained into a soft, pudding-like consistency) meals to three times a day regular mechanical soft textures
(foods that are easy to chew and swallow, requiring minimal effort) meals, reviewed under the nutrition care
area.
This deficient practice had the potential for Resident 185 to not receive the proper and necessary care
regarding her new diet order.
b. There was no care plan developed and implemented addressing a Resident 59's pressure ulcer/injury
(localized damage to the skin and/or underlying tissue usually over a bony prominence) and treatments,
reviewed under the care area of pressure ulcer/injury.
This deficient practice had the potential to result in a failure to deliver the necessary care and services
necessary to treat Resident 59's pressure ulcer/injury.
Findings:
a. During a review of Resident 185's admission Record, the admission Record indicated the facility
admitted Resident 185 on 4/2/2025 from the sub-acute unit with diagnoses including diffuse traumatic brain
injury (TBI-a widespread disruption in the normal function of the brain that can be caused by a bump, blow,
or jolt to the head)) with loss of consciousness (when a person is neither awake or aware of the external
environment), gastronomy (a surgical opening fitted with a device to allow feedings to be administered
directly to the stomach common for people with swallowing problems) and tracheostomy (a surgical
procedure that creates an opening in the trachea [tube from mouth to lungs] to allow air to enter the lungs.
During a review of Resident 185's History and Physical (H&P), dated 4/3/2025, the H&P indicated Resident
185 did not have the capacity to understand and make decisions.
During a review of Resident 185's Minimum Data Set (MDS - an assessment and care screening tool)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 16 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0656
Level of Harm - Minimal harm
or potential for actual harm
dated 5/2/2025, the MDS indicated Resident 185 was able to understand others and make herself
understood, but forgetful with poor orientation and recall and dependent on staff for eating. The MDS
further indicated Resident 185 had a tube feeding (gastrostomy), received 51% or more of her nutrition
from tube feeding and received speech therapy (treatment that improves your ability to talk and use other
language skills, also assessment for a patient's ability to swallow safely)
Residents Affected - Some
During a review of Resident 185's Physician's Order on 5/5/2025, the Physician's Order indicated the
following orders:
-discontinue oral gratification diet - puree texture, nectar/mildly thick consistency, 1:1 feeding for two (2)
portions during lunch and dinner.
-start regular diet, mechanical soft texture, thin consistency for 3 meals, 1:1 feeding.
During an interview with Certified Nursing Assistant 6 (CNA 6) on 5/6/2025 at 11:25 am, CNA 6 stated
Resident 185 had pureed diet for lunch and dinner only with one-to-one supervision. CNA 6 stated she was
unaware of the diet order change from 5/5/2025 nor was she notified of the change.
During a concurrent interview and record review on 5/6/2025 at 4:03 am with Registered Nurse 1 (RN 1),
RN 1 stated she was unaware of Resident 185's diet order change. RN 1 looked through Resident 185's
care plan and was not able to locate a care plan with interventions for the new diet order change and stated
without a care plan with interventions, staff may not know how to properly assist Resident 185 with her
meals. RN 1 further stated it is very important to follow all the speech therapists orders to make sure the
resident does not aspirate or choke.
During a concurrent interview and record review with the Director of Nursing (DON), the DON stated
according to the care plan policy, assessments of the residents are ongoing, and care plans are revised as
information about the residents and their condition changes. The DON further stated her staff should have
created a new care plan for Resident 185's significant diet order change for other staff members to know
how to properly care for the residents.
During a review of the facility provided Policy and Procedure (P&P) titled, Care Plans, Comprehensive
Person-Centered last reviewed on 7/16/2024, the P&P indicates a comprehensive, person-centered care
plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and
functional needs is developed and implemented for each resident. The P&P further indicates assessments
of the residents are ongoing, and care plans are revised as information about the residents and their
condition changes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 17 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on interview and record review, the facility failed to update and revise a resident's care plan (a
document that summarizes a resident's needs, goals, and care/treatment) after the resident's restraint
freedom splint (multipurpose soft splints that help restrict elbow and knee movement) was discontinued, for
one of two sampled residents (Resident 63).
This deficient practice had the potential to result in confusion in the delivery of care and service.
Findings:
During a review of Resident 63's admission Record, the admission Record indicated that the facility
admitted the resident on 2/14/2018 and readmitted the resident on 6/17/2024 with diagnoses including
acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of
breath and difficulty breathing), encephalopathy (brain disease, damage, or malfunction of brain), chronic
respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) with
hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and quadriplegia
(paralysis [complete or partial loss of muscle function] of all four limbs).
During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool) dated 3/20/2025,
the MDS indicated that the resident had severely impaired cognitive skills (mental abilities, including
remembering things, making decisions, concentrating, or learning). The MDS indicated that Resident 63
was totally dependent on staff with all activities of daily living (ADLs - activities related to personal care).
During a review of the Resident 63's care plan, revised on 3/26/2025, the care plan indicated that Resident
63 had a restraint freedom splint and was at high risk for injury and complications due to pulling life
sustaining equipment.
During a review of Resident 63's physician order dated 4/17/2025, the physician order indicated to
discontinue freedom splint to left upper extremity.
During a concurrent interview and record review on 5/7/2025 at 3:51 p.m., with the Subacute Director (SD),
reviewed Resident 63's care plans. The SD stated that Resident 63 did not have episodes of pulling their
tracheostomy tube (an opening created at the front of the neck so a tube can be inserted into the windpipe
[trachea] to help you breathe) for the last three months and the physician discontinued the order for
freedom splint on 4/16/2025. The SD stated licensed staff did not revise or update Resident 63's care plan
addressing that resident's freedom splint was discontinued. The SD stated licensed staff are required to
revise a resident's care plan after a resident's condition changed to ensure the effectiveness of care plan
interventions. The SD stated the potential outcome of not updating/revising a resident's care plan is the
inability to provide appropriate care and monitoring to the resident.
During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated that
residents' care plans are required to be reviewed and revised after residents' change of condition. The DON
stated Resident 63's care plan was not revised or updated after Resident 63's restraints
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 18 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
were discontinued. The DON stated the potential outcome of not updating/revising a resident's care plan is
the inability to provide appropriate care and services to the resident.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive
Person-Centered, last reviewed on 7/16/2025, the P&P indicated that care plan interventions are chosen
only after data gathering, proper sequencing of events, careful consideration of the relationship between
the resident's problem areas and their causes, and relevant clinical decision making. Assessments of
resident's are ongoing and care plans are revised as information about the residents and the residents'
conditions change.
Event ID:
Facility ID:
056149
If continuation sheet
Page 19 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of one sampled resident
(Resident 156) was provided a communication device or board (a tool that includes pictures that help
residents communicate their healthcare and every-day needs to facility staff) in her preferred language in
order to effectively communicate with staff.
Residents Affected - Few
This deficient practice prevented Resident 156 from communicating with the staff and receiving care in a
timely manner.
Findings:
During a review of Resident 156's admission Record (face sheet), the admission Record indicated that the
facility admitted the resident on 3/26/2024, with diagnoses including dysphagia (difficulty swallowing),
essential hypertension (HTN-high blood pressure), and need for assistance with personal care. The
admission Record further indicated that Resident 156`s primary language was Chinese.
During a review of Resident 156's Minimum Data Set (MDS - a resident assessment tool) dated 4/8/2025,
the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor,
cues/supervision required). The MDS indicated that Resident 156 was dependent on staff (helper does all
of the effort) for toileting hygiene, showering/bathing, lower body dressing, putting on/talking off footwear,
and personal hygiene. The MDS further indicated that Resident 156`s preferred language was Chinese,
and the resident needed or wanted an interpreter to communicate with a doctor or health care staff.
During a review of Resident 156's care plan (a document that outlines how a patient's health care needs
will be met) for cognitive and communication deficit (a problem or difficulty in the brain's functions, such as
memory, attention, problem-solving and speaking) initiated on 4/7/2024, the care plan indicated a goal that
the resident`s needs will be anticipated and met daily until the next assessment date. The care plan
interventions were to speak clearly and slowly to the residents, explain all procedures and reasons prior to
initiating care and treatment and to utilize translator or communication devices as indicated.
During a concurrent observation and interview on 5/7/2025 at 11:00 a.m. inside the facility`s activity room,
Resident 156 was observed sitting on her wheelchair using her cellphone. The Activity Assistant (AA) was
present next to Resident 156 and stated that Resident 156 speaks Chinese and does not understand
English well. The AA stated staff are using Resident 156`s cellphone to translate from English to Chinese.
The AA stated a communication board with pictures and signs is required for residents who do not speak
English. The AA started looking for a communication board/device on Resident 156 wheelchair. However,
she did not find one. The AA stated there is no communication board and device inside the activity room
either. The AA confirmed that Resident 156 spends a lot of time in the activity room and staff have a hard
time communicating with her.
During a concurrent observation and interview on 5/7/2025 at 11:05 p.m., with the Activity Director (AD),
inside Resident 156`s room, the AD stated for the residents who are not able to communicate their needs in
English, the facility places a communication board/device at the residents` bed side.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 20 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0676
Level of Harm - Minimal harm
or potential for actual harm
The AD stated that Resident 156 speaks Chinese and requires a communication board at her bedside to
be able to make her needs known. The AD started looking for a communication board/device at Resident
156`s bedside. However, she (AD) was not able to find one. The AD stated that the potential outcome of not
having a communication board available and accessible to a resident who is not able to communicate
effectively in English is inability to meet the resident's needs.
Residents Affected - Few
During a concurrent observation and interview on 5/7/2025 at 12:10 p.m., inside the facility`s small dining
room, Resident 156 was observed eating lunch and sitting with Responsible Party 1 (RP 1). RP1 stated that
Resident 156 is alert and able to express her needs. RP 1 stated that Resident 156 speaks Mandarin (one
of the dialects of Chinese). RP 1 did not find a communication [NAME] or device attached to Resident
156`s wheelchair. Resident 156 stated that she often does not have a communication board/device, and
she normally uses gestures to make her needs known. Resident 156 stated she wishes she knew how to
speak English so that she can express her needs.
During an interview on 5/8/2025 at 3:08 p.m., with the Director of Nursing (DON), the DON stated staff are
required to provide a communication board or device to the residents who do not speak English in the
language that they speak. The DON stated Resident 156 was not provided a communication device/board
in Chinese. The DON stated the potential outcome of not providing a communication board/device to the
residents who do not speak English is the inability to communicate with residents accurately and
understand their needs.
During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Related to
Communication Deficits, last reviewed on 7/16/2024, the P&P indicated that communication needs will be
identified and appropriate interventions including care planning will be developed in order to accommodate
the needs of the resident. The care plan will be developed, updated quarterly and as indicated to reflect
accurate, current assessments related to communication needs.
During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs),
Supporting, last reviewed on 7/16/2024, the P&P indicated that appropriate care and services will be
provided for residents who are unable to carry out ADLs independently, with the consent of the resident and
in accordance with the plan of care, including appropriate support and assistance with communication (
speech, language, and any functional communication system).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 21 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure residents receive treatment
and assistive devices to maintain hearing abilities for one of one resident (Resident 5) reviewed under the
communication/sensory care area when Resident 5 was not provided with an audiology consultation for his
impaired hearing.
Residents Affected - Some
This failure prevented Resident 5 from receiving the services and equipment needed to improve his hearing
ability.
Findings:
During a review of Resident 5's admission Record, the admission Record indicated the facility admitted
Resident 5 on 2/28/2024 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by
difficulty in blood sugar control and poor wound healing), heart failure (a condition where the heart muscle
is weakened and cannot pump blood effectively enough to meet the body's need), acute kidney failure (a
sudden and significant loss of kidney [organ that filters blood] function), and depression (persistent feelings
of sadness, hopelessness, and loss of interest in activities previously enjoyed).
During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening
tool), dated 3/12/2025, the MDS indicated Resident 5 has some memory issues but is understood and able
to understand others. The MDS further indicated Resident 5 had adequate (no difficulty in normal
conversation, social interaction, listening to TV) hearing.
During a review of Resident 5's Order Summary Report, the Order Summary Report indicated an active
order dated 2/28/2024, for an audiology (a branch of science dealing with hearing) consult PRN (as
needed) for hearing problems.
During a review of Resident 5's Social Service Assessment (Hearing) dated 12/12/2024, the assessment
indicates Resident 5 has an impaired hearing pattern and hearing appliances and consultation are not
indicated. Further review did not indicate a Social Service Assessment (Hearing) was conducted for the first
quarter of 2025.
During an interview on 5/5/2025 at 10:50 am with Resident 5 in Resident 5's room, Resident 5 stated he
has a hard time hearing and has been waiting for approximately six months for hearing aids. Resident 5
stated about four or five months ago, he went to see the ear doctor but was told because they were late, he
could not be seen. Resident 5 stated, and he was told he would be seen at the facility instead, but no one
has seen him yet. Resident 5 further stated his favorite activity is watching TV, but it was very hard for him
to hear it.
During a concurrent interview and record review on 5/7/2025 at 1:35pm with the Social Service Director
(SSD), the SSD stated Resident 5 saw the ENT (ear, nose, throat doctor) on 11/26/24 and recommended
an audiology exam for hearing aids. The SSD then stated Resident 5 had an audiology appointment on
2/3/2025, but they could not accommodate a gurney and the follow-up audiology appointment on 2/10/2025
was cancelled because the audiology office could not accommodate a gurney. The SSD stated the facility
did not offer audiology services in-house. The SSD stated the social services staff that completed the
Social Service Assessment (Hearing) form on 12/12/2024 no longer works at the facility and should have
checked off a hearing consultation is needed. The SSD stated she should have
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 22 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0685
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
completed a Social Service Assessment (Hearing) this past quarter to ensure Resident 5 received the
services he needed. The SSD further stated six months is too long of a wait for hearing aids and she
should have prioritized Resident 5.
During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, last reviewed on
7/16/2024, the policy and procedure indicated that all persons who have completed any portion of the MDS
resident assessment form sign the document attesting to the accuracy of information.
During a review of the facility's P&P titled, Hearing Impaired Resident, Care Of, the P&P indicated staff will
assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other
residents and visitors. The P&P indicated the facility does not provide comprehensive audiological
evaluations or devices to assist with hearing and staff will assist the resident (or representative) with
locating available resources, scheduling appointments and arranging transportation to obtain needed
services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 23 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
1.b. During a review of Resident 36's admission Record, the admission Record indicated that the facility
originally admitted the resident on 7/6/2014 and readmitted the resident on 4/29/2025 with diagnoses
including metabolic encephalopathy (a condition where brain dysfunction results from a problem with the
body's metabolism, causing a change in brain function), legal blindness, and a history of falling.
During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2025,
the MDS indicated that the resident had intact cognition (thought processes) and was dependent on staff
for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs
daily).
During a review of Resident 36's Fall Risk Assessment, dated 3/4/2025, the Fall Risk Assessment indicated
that the resident was at high risk for falls.
During a review of Resident 36's physician's order, dated 5/1/2025, the order indicated to provide the
resident with a floor mat to decrease potential injury every shift.
On 5/7/2025 at 2:41 p.m., during an observation, observed Resident 36 asleep in bed. No floor mats were
observed in the room.
On 5/7/2025 at 4:04 p.m., during a concurrent observation and interview, observed Resident 36 in bed.
Certified Nursing Assistant 4 (CNA 4) stated she was the assigned CNA for Resident 36. CNA 4 verified
that the resident was at high risk for falls and did not currently have floor mats.
On 5/8/2025 at 11:18 a.m., during an interview with the Director of Nursing (DON), the DON stated if the
resident was not provided with the prescribed floor mats, then the resident could potentially have a fall
resulting in injury.
During a review of the facility's policy and procedure titled, Falls - Clinical Protocol, last reviewed on
7/16/2024, the policy and procedure indicated that, based on the assessment, the staff and physician will
identify pertinent interventions to try to prevent falls and to address risks of serious consequences of falling.
Based on observation, interview, and record review, the facility failed to provide an environment that is free
from accident hazards for four (Resident 36, 61, 80 and 182) of six sampled residents reviewed under the
accidents care area by:
1. Failing to place floor mats (a floor pad designed to help prevent injury should a person fall) on both sides
of the Resident 61 and Resident 36's beds as ordered by the physician.
2. Failing to ensure Resident 182's bed rail padding was intact and did not have a large rip that exposed the
hard bed rail for a resident with an order for padded bed rails to decrease potential injuries.
3. Failing to ensure Resident 80 had accurate fall risk assessments.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 24 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0689
These deficient practices had the potential to place Residents 36, 61, 80 and 182 at risk for injuries.
Level of Harm - Minimal harm
or potential for actual harm
Findings:
Residents Affected - Some
1.a During a review of Resident 61's admission Record (face sheet), the admission record indicated that
the facility admitted the resident on 4/22/2024, with diagnoses including history of falling, muscle weakness,
and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled
jerking, blank stares, and loss of consciousness).
During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2025, the
MDS indicated the resident's cognitive skills (the brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor,
cues/supervision required). The MDS indicated that Resident 61 was dependent on staff (helper does all
the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting
on/taking off footwear, and personal hygiene. The MDS further indicated that Resident 61 had one fall since
his admission/entry to the facility.
During a review of Resident 61's Order Summary Report (physician order) dated 10/30/2024, the order
summary report indicated to place floor mat on both sides of the resident`s bed to decrease potential
injuries due to fall.
During a review of Resident 61's Change of Condition (COC-an improvement or worsening of a patient`s
condition which was not anticipated) Interact Assessment form dated 11/30/2024, the COC assessment
form indicated that the resident slid off his wheelchair in the dining room.
During a review of Resident 61's care plan (a document that outlines how a patient's health care needs will
be met) for actual fall initiated on 11/30/2024, and last revised on 12/2/2024, the care plan indicated a goal
that the resident will have minimum risk for falls/injury through appropriate interventions until the next
assessment. The care plan interventions were to place the resident`s bed in a low position, and to place
floor mats at the resident`s bedside.
During a concurrent observation and interview on 5/8/2025 at 8:46 a.m., inside Resident 61's room, the
resident was observed in his bed. Certified Nursing Assistant 3 (CNA 3) was sitting next to the resident and
assisting him with his breakfast. CNA 3 stated there is no floor mat at Resident 61's bedside as a fall
precaution.
During a concurrent interview and record review on 5/8/2025 at 8:50 a.m., with Registered Nurse 1 (RN 1),
Resident 61`s physician orders were reviewed. RN 1 stated Resident 61`s physician ordered to place floor
mats at the resident`s bedside to decrease the potential injuries due to a fall.
During a concurrent observation and interview on 5/8/2025 at 8:53 a.m., inside Resident 61's room with RN
1, RN 1stated that Resident 61 did not have any floor mats at his bedside as ordered by his physician and
the potential outcome is injuries if a fall occurs.
During an interview on 5/8/2025 at 3:11 p.m., with the Director of Nursing (DON), the DON stated that
Resident 61 is considered a high risk for falling and his physician ordered to place floor mats on both sides
of his bed. The DON stated staff did not place floor mats at Resident 61's bedside and the potential
outcome is insufficient care and increased risk of injuries after a fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 25 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0689
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's Policy and Procedure (P&P) titled Falls - Clinical Protocol, last reviewed on
7/16/2024, the P&P indicated that based on the proceeding assessment, the staff and physician will identify
pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of
falling. The staff and physician will monitor and document the individual`s response to interventions
intended to reduce falling or the consequences of falling.
Residents Affected - Some
During a review of the facility's Policy and Procedure (P&P) titled Low Bed - Floor Mat, not a Restraint, last
reviewed on 7/16/2024, the P&P indicated that the facility does not consider the use of low bed and floor
mat as a restrain. The use of low bed and floor mat is the least restrictive measure when a resident is in
bed.
3. During a review of Resident 80's admission Record, the admission Record indicated the facility originally
admitted the resident on 9/3/2021 and readmitted the resident on 10/29/2023 with diagnoses including
metabolic syncope (fainting, or a sudden temporary loss of consciousness), major depression (a mood
disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily
activities of living), and seizures (a burst of uncontrolled electrical activity between brain cells that caused
temporary abnormalities in muscle tone or movements) and history of fall.
During a review of Resident 80's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025,
the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering
things, making decisions, concentrating, or learning) was able to make herself understood and usually
understands others. The MDS further indicated Resident 80 required supervision of staff to complete most
activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 80's Care plan initiated on 06/03/2023, the Care plan indicated that Resident
80 was on Falling Star Program and was at risk for fall.
During a review of Resident 80's Change of Condition (COC) Assessment Form, dated 10/14/2024, the
COC Assessment Form indicated Resident 80 was found on the floor in his room. The COC Assessment
Form further indicated Resident 80 stated he tried getting up from the bed to go to the bathroom and fell.
During a concurrent interview and record review on 5/8/2025 at 1:39 p.m. with Director of Nursing (DON),
Resident 80's Fall Risk Evaluations, dated 10/14/2024 and 4/15/2025 were reviewed. The D section of the
Fall Risk Evaluation dated 10/14/2024 titled Predisposing factors, did not reflect seizures as a predisposing
factor. The DON stated that the Fall Risk Evaluation should reflect all predisposing conditions including
seizures. The second section of Resident 80's Fall Risk Assessment, dated 4/15/2025 titled History of Falls
for past three months was blank. The DON stated it is important to accurately complete the Fall Risk
Assessment so staff are aware of Resident 80's risk of falling and staff can effectively care for the resident.
During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, last revised
7/16/2025, the P&P indicated: The staff will document risk factors for falling in the resident's record and
discuss resident's fall risk.
2. During a review of Resident 182's admission Record, the admission Record indicated the facility
originally admitted the resident on 3/29/2025 and readmitted the resident on 4/29/2025 with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 26 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
diagnoses including but not limited to cerebral infarction (an obstruction of blood flow in the brain that leads
to tissue damage) and acute respiratory failure (a condition where the lungs cannot release enough oxygen
into the blood).
During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025,
the MDS indicated Resident 182 had severely impaired cognitive skills (problems with the ability to think,
learn, and remember clearly) for daily decision making and required total assistance from staff with
activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 182's Physicians Orders, the Physicians Orders indicated an order for padded
bed rails to decrease potential injury dated 4/30/2025.
During a review of Resident 182's care plan titled Resident is on Padded siderails, dated 3/30/2025, the
care plan indicated the resident needs padded bed rails to prevent or reduce incidences of injuries.
During a concurrent observation and interview on 5/8/2025 at 10:51 a.m. with the Subacute Director (SD),
Resident 182's upper left bed rail padding had a large rip which exposed the hard bed rail. The SD stated
the padding should be replaced due to the rip. The SD stated that because the bed rail is exposed due to
the rip the padding would not protect the resident from injuries.
During an interview on 5/8/2025 at 2:39 p.m. with the Director of Nursing (DON), the DON stated the ripped
bed rail padding on Resident 182's upper left bed rail could potentially result in injuries to Resident 182.
During a review of the facility's policy and procedure (P&P) titled Homelike Environment, last reviewed
7/16/2024, the P&P indicated residents are to be provided with a safe, clean, comfortable, environment.
During a review of the facility's P&P titled Bed Safety and Bed Rails, last reviewed 7/16/2024, the P&P
indicated potential risks with the use of bed rails are assessed including accident hazards and skin integrity
issues.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 27 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, interview, and record review, the facility failed to ensure one of two sampled
residents (Resident 540) was provided a toileting program and/or bowel and bladder training (when facility
staff assist a resident to the restroom at specific timed intervals) to restore as much bladder function as
possible.
This deficient practice had the potential to result in continued urinary incontinence (the involuntary leakage
or loss of bladder control, resulting in unintended urination), development of urinary tract infection (UTI- an
infection in any part of the urinary system), and potential to not achieve or restore normal bowel and
bladder function.
Findings:
During a review of Resident 540's admission Record, the admission Record indicated the facility originally
admitted the resident on 4/6/2025 with diagnoses including acute and chronic respiratory failure (condition
in which not enough oxygen passes from your lungs into your blood), acute kidney failure (a condition in
which the kidneys are damaged and cannot filter blood well), and type two (2) diabetes mellitus (a chronic
condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 540's Minimum Data Set (MDS - a resident assessment tool) dated 4/18/2025,
the MDS indicated the resident had intact cognition (mental abilities, including remembering things, making
decisions, concentrating, or learning) and required moderate - to - maximal assistance from staff for most
activities of daily living (ADLs - activities related to personal care).
During a review of Resident 540's Baseline Care Plan (a document that summarizes a resident's needs,
goals, and care/treatment) dated 4/6/2025, the care plan indicated that Resident 540 was admitted with an
indwelling catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) and
required catheter care.
During a review of Resident 540's Bowel and Bladder Screener dated 4/9/2025, the Bowel and Bladder
Screener indicated that Resident 540 was a poor candidate for retraining/scheduled toileting.
During a review of Resident 540's physician orders, the physician orders indicated an order to discontinue
indwelling catheter, dated 4/18/2025.
During a review of Resident 540's Care Plan dated 4/21/2025, the Care Plan indicated that the resident had
alteration in elimination patterns related to being always incontinent for bowel and bladder and was not
retrainable for bladder and bowel.
During a review of Resident 540's Elimination Flowsheet dated 5/7/2025, the Elimination Flowsheet
indicated that Resident 540 was continent (the ability to control movements of the bowels and bladder) four
times in the last seven days on 5/3/2025, 5/5/2025, 5/6/205 and 5/7/2025.
During a concurrent observation and interview on 5/5/2025 at 9:51 a.m., with Resident 540 in Resident
540's room, observed Resident 540 walking to the bathroom independently. Resident 540 stated that he
was not provided with any bladder retraining program in the facility and he would like to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 28 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
participate in bladder retraining program because he is able to feel the urge to go to bathroom when he is
awake but is not be aware of the need to toilet when he is sleeping.
During an interview on 5/7/2025 at 8:34 a.m., with the Assistant Director of Nursing (ADON), the ADON
stated that she did Resident 540's Bowel and Bladder Screening on 4/9/2025. The ADON stated that
Resident 540 was not a candidate for bladder retraining program due to sleepiness and forgetfulness. The
ADON stated that the resident should be screened one more time after he becomes more mobile and alert
after his indwelling catheter was removed and put on bladder training program to restore as much bladder
function as possible.
During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated that the
licensed nursing staff did not repeat a bowel and bladder program screening when Resident 540 became
more alert and independent and did not provide Resident 540 with an individualized bowel and bladder
retraining program.
During a review of the facility's policy and procedure titled, Bladder and Bowel Assessment, dated
7/16/2024, the policy indicated bladder and bowel assessment will be completed within 14 days from
admission/readmission and updated quarterly. And based on the score, the care plan is developed and the
care planned.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 29 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that one of one sampled resident
(Resident 15), who was receiving nutrition by gastrostomy tube (GT-a surgical opening fitted with a device
to allow feedings to be administered directly to the stomach common for people with swallowing problems),
received appropriate care and services to prevent complications of enteral feeding (tube feeding, a way of
delivering nutrition directly to your stomach or small intestine).
This deficient practice had the potential to lead to the inadequate care of Resident 15 and place the
resident at an increased risk for complications such as infection.
Findings:
During a review of Resident 15's admission Record (face sheet), the admission record indicated that the
facility originally admitted the resident on 11/21/2024 and readmitted on [DATE], with diagnoses including
tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs),
gastrostomy, and dementia (a progressive state of decline in mental abilities).
During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated 4/15/2025,
the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made
decisions). The MDS indicated that Resident 15 was dependent on staff (helper does all of the effort) for
oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, and personal
hygiene. The MDS further indicated that Resident 15 was receiving nutrition via gastrostomy tube while a
resident in the facility.
During a review of Resident 15`s care plan (a document outlining a detailed approach to care customized
to an individual resident's need) for GT feeding initiated on 1/14/2025 and last revised on 4/30/2025, the
care plan indicated a goal that the resident will have minimum risk of infection at his GT site until the next
assessment date. The care plan interventions were to provide GT care daily, and assess the skin for
redness, pain, swelling, discharge and report to the physician if any present.
During a review of Resident 15`s physician Order Summary Report dated 5/5/2025, the Order Summary
Report indicated an order to clean the GT site with normal saline (NS- a saltwater solution), pat dry, and
cover with dry dressing during every day shift.
During a concurrent observation and interview on 5/7/2025 at 11:17 a.m., with Certified Nursing Assistant 2
(CNA 2), inside Resident 15's room, CNA 2 stated that there is no dressing present on Resident 15`s GT
insertion site. CNA 2 stated the facility`s Treatment Nurse (TN) is in charge of providing skin care and
dressing to residents` GT sites.
During a record review of Resident 15`s Treatment Administration Record (TAR-a daily documentation
record used by a licensed nurse to document treatments given to a resident) on 5/7/2025 at 12:40 p.m., the
TAR indicated that Treatment Nurse 1 (TN 1) documented that he provided treatment to the resident`s GT
site during day shift on 5/7/2025.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 30 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent observation and interview on 5/7/2025 at 1:10 p.m., with CNA 2, inside Resident 15's
room, CNA 2 stated that there is no dressing present on Resident 15`s GT insertion site.
During a concurrent observation and interview on 5/7/2025 at 1:20 p.m., with TN 1 inside Resident 15's
room, TN 1 confirmed that there was no dressing on Resident 15`s GT insertion site. TN 1 stated that he
provided skin care and placed a dressing on Resident 15`s GT insertion site today at around 9.00 a.m.
However, TN 1 stated that he documented in the Resident 15`s TAR that he (TN 1) provided care today at
12:32 p.m. TN 1 stated that he (TN 1) is not sure what happened to the dressing and that Resident 15 must
have removed it. TN 1 stated that he (TN 1) is required to document in the residents` medical record right
after completing his task so that the documentation reflects the correct time wound care had been
provided. TN 1 stated that the potential outcome of not performing skin care, and not placing the dressing
on the GT site is infection.
During an interview on 5/8/2025 at 3:04 p.m., with the Director of Nursing (DON), the DON stated that
licensed staff are required to provide skin care to GT insertion site daily and document in the residents`
TAR immediately after completion of the task. The DON stated, If the dressing is not there, it is not done.
The DON stated the potential outcome of not performing skin care and placing dressing to a resident`s GT
site is infection.
During a review of the facility`s Policy and Procedure (P&P) titled Enteral Nutrition, last reviewed 7/16/2024,
the P&P indicated that staff caring for residents with feeding tubes are trained on how to recognize and
report complications associated with the insertion and/or use of feeding tube such as skin breakdown
around insertion site.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 31 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to
Residents Affected - Few
1. Ensure that a resident received oxygen as ordered by the physician for one of two sampled residents
(Resident 107) reviewed under Respiratory Care area.
2. Ensure that Resident 107`s oxygen tubing had a label indicating the date and time of when it was last
changed.
3. Ensure that Resident 107`s oxygen humidifier (a medical device used to add moisture to supplemental
oxygen, making it easier and more comfortable to breathe, especially for patients using oxygen therapy for
extended periods ) was full.
These deficient practices had the potential to place Resident 107 at an increased risk of infection and
cause complications associated with oxygen therapy.
Findings:
During a review of Resident 107's admission Record (face sheet), the admission Record indicated that the
facility originally admitted the resident on 4/19/2021 and readmitted on [DATE], with diagnoses including
acute (appear rapidly) and chronic (a condition that lasts longer than three months) respiratory failure (a
serious condition that makes it difficult to breathe on your own) with hypoxia (a medical condition where
there is an inadequate supply of oxygen to the body's tissues), type two diabetes mellitus (DM-a disorder
characterized by difficulty in blood sugar control and poor wound healing), and history of falling.
During a review of Resident 107's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2025,
the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reliable).
The MDS indicated that Resident 107 required the staff substantial/maximal assistance (helper does more
than half the effort) for oral hygiene, and upper body dressing. The MDS indicated that Resident 107 was
dependent on staff (helper does all of the effort) for toileting hygiene, showering and bathing, lower body
dressing, putting on/talking off footwear and personal hygiene. The MDS further indicated that Resident 107
was receiving oxygen therapy while a resident in the facility.
During a review of Resident 107's physician Order Summary Report (physician orders) dated 11/15/2024,
the order summary report indicated to administer oxygen at two liters per minute via nasal cannula (NC-a
small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) for shortness of
breath (SOB) and chronic respiratory failure. The order summary report indicated to titrate (to carefully
adjust the amount of oxygen a patient receives to achieve a specific, target level of oxygen saturation in the
blood) the oxygen level up to three liters per minute to keep the resident`s oxygen saturation (a
measurement of how much oxygen your blood is carrying compared to its maximum capacity-for healthy
adults, normal oxygen saturation is between 95% and 100%) above 90%. The order summary report further
indicated to change the oxygen tubing every Sunday during night shift.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 32 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0695
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 107`s care plan (a document outlining a detailed approach to care customized
to an individual resident's need) for oxygen, initiated on 4/30/2021 and last revised on 8/18/2024, the care
plan indicated a goal that the resident will be free of adverse effects related to use of oxygen. The care plan
interventions were to administer oxygen as per physician order, monitor the resident`s oxygen saturation,
change the oxygen tubing weekly or as needed and to check the rate of oxygen flow during every shift.
Residents Affected - Few
During a concurrent observation and interview on 5/5/2025 at 10:12 a.m. with Certified Nursing Assistant 1
(CNA1) inside Resident 107`s room, Resident 107 was observed sitting on her bed receiving oxygen. CNA
1 stated that Resident 107 was receiving oxygen at six liters per minute via NC. CNA 1 stated that Resident
107`s oxygen tubing did not have a label including the date and time of when it was last changed. CNA 1
stated that the humidifier connected to Resident 107`s oxygen machine was empty.
During a concurrent observation and interview on 5/5/2025 at 10:16 a.m. with Licensed Vocational Nurse 2
(LVN 2) inside Resident 107`s room, LVN 2 stated that Resident 107`s physician ordered to administer
oxygen at two liters per minute via NC. However, Resident 107 receives oxygen at six liters per minute via
NC. LVN 2 stated that Resident 107`s oxygen tubing did not have a label with the date and time of when it
was last changed. LVN 2 stated Resident 107`s oxygen humidifier was empty. LVN 2 stated that the facility
staff are required to change oxygen tubing once a week on Sundays. LVN 2 stated the potential outcome of
not changing a resident`s oxygen tubing once per week as ordered by the physician is placing the resident
at risk for infection. LVN 2 further stated that Resident 107 was receiving oxygen at a greater rate than it
was ordered by her physician. LVN 2 stated delivering too much oxygen via NC may be harmful to Resident
107. LVN 2 stated licensed nurses are required to ensure that the oxygen humidifier is full to prevent nostril
dryness. LVN 2 stated that he (LVN 2) failed to monitor Resident 107 appropriately to ensure that she is
receiving the correct rate of oxygen, that the humidifier is full and the oxygen tubing is dated.
During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated licensed
staff are required to implement physician orders for administration of oxygen to residents. The DON stated
that the facility staff are required to change the oxygen tubing once per week as ordered by the physician
and label the tubing with the date and time it was changed. The DON stated licensed staff are required to
monitor residents` oxygen humidifier to ensure the container is full. The DON stated the potential outcome
of not changing and labeling the oxygen tubing and humidifier is the increased risk of infection for the
residents. The DON stated the potential outcome of administering oxygen more than the physician`s
ordered flow rate via NC is difficulty breathing and harm to the resident.
During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, last reviewed on
7/16/2024, the P&P indicated that oxygen will be administered to residents as needed per attending
physician`s orders by licensed personnel. Review oxygen order(s) for oxygen use. Administer oxygen as
per physician`s orders. Oxygen administered at three liters per minutes pr more requires humidifier. The
oxygen tubing should be changed weekly and as needed. The date, time, and initials should be noted on
oxygen equipment when it is initially used and when changed. Since oxygen is based on a physician`s
order, it is considered a licensed staff procedure.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 33 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure non-pharmacological interventions
(treatments or therapies that do not involve the use of medications) were attempted prior to administering
as needed oxycodone (a drug used to treat moderate to severe pain) for one of two sampled residents
(Resident 100).
Residents Affected - Few
This deficient practice placed Resident 100 at increased risk of experiencing adverse side effects
(undesired harmful effect resulting from a medication or other intervention) from oxycodone such as
drowsiness, increased risk of falling, or loss of appetite.
Findings:
During a review of Resident 100's admission Record, the admission Record indicated the facility originally
admitted the resident on 9/19/2020 and readmitted the resident on 3/29/2025 with diagnoses including but
not limited to sarcoma (a group of cancers which start in the bones and connective tissue), pain in the right
knee, and aftercare following surgery for a neoplasm (abnormal and excessive growth of tissue).
During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025,
the MDS indicated Resident 100 had intact cognition (can think, learn, and remember clearly) and required
total assistance or substantial assistance from staff for most activities of daily living (ADLs- activities such
as bathing, dressing and toileting a person performs daily).
During a review of Resident 100's physician orders, the physician orders indicated the following:
- Oxycodone 5 milligram (mg- unit of measurement) oral tablets: give one tablet by mouth every four hours
as needed for severe pain, ordered 4/12/2025.
- Non-pharmacological pain interventions: 1- reposition, 2-dim lights, 3-distraction, 4-relaxation techniques,
5-hot/cold applications, 6-music, 7-massage, 8-other. Document result and effectiveness of intervention. If
ineffective administer appropriate pain medication as ordered, ordered 2/17/2025.
During a concurrent interview and record review on 5/7/2025 at 12:02 p.m., with Licensed Vocational Nurse
5 (LVN 5), reviewed Resident 100's Medication Administration Record (MAR - a daily documentation record
used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025.
Resident 100's MAR indicated there was no documentation that non-pharmacological pain interventions
were attempted prior to administering oxycodone on 4/14/2025 at 9:00 a.m. LVN 5 stated Resident 100
should be offered non-pharmacological pain interventions before giving pain medication because there is
an order to try non-pharmacological options first and it is important to follow that protocol.
During a concurrent interview and record review on 5/8/2025 at 12:18 p.m., with Registered Nurse 3 (RN
3), reviewed Resident 100's MAR dated 4/2025. Resident 100's MAR indicated there was no
documentation that non-pharmacological pain interventions were attempted prior to administering
oxycodone on 4/16/2025 at 11:45 a.m. and 4/24/2025 at 12:50 p.m. RN 3 stated she was not sure why
there was no documentation of non-pharmacological pain interventions before she administered oxycodone
at those times. RN 3 stated it is important to try non-pharmacological pain interventions first because that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 34 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0697
might relieve the resident's pain, and the pain medication may be unnecessary.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/8/2025 at 2:39 p.m. with the Director of Nursing (DON), the DON stated
non-pharmacological pain interventions should be tried first before giving pain medications. The DON
stated they need to see if non-pharmacological pain interventions would relieve the pain before considering
pain medication.
Residents Affected - Few
During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, last
reviewed 7/16/2024, the P&P indicated non-pharmacological interventions including adjusting room
temperature, repositioning, ice packs, range of motion exercises, and diversions may be appropriate
interventions alone or in conjunction with medications. The P&P further indicated pain medications can
manage pain but can also have adverse effects including drowsiness, increased risk of falling, or loss of
appetite.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 35 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure a resident who received dialysis (a
treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s)
have failed) received treatment in accordance with standards of practice for one of four sampled residents
reviewed under the dialysis care area (Resident 160) by:
Residents Affected - Few
1. Failing to assess the resident`s right upper chest quinton catheter (non-tunneled central line catheters,
which are often used as temporary access for hemodialysis) dialysis access site.
2. Failing to implement the physician's order for fluid restriction (limiting the amount of liquid a person
consumes daily, often prescribed to manage kidney disease) limited to no water pitcher at the resident`s
bedside.
These deficient practices had the potential to place Resident 160 at risk for fluid overload (a condition
where you have too much fluid volume in your body)
and infection.
Findings:
During a review of Resident 160's admission Record (face sheet), the admission Record indicated that the
facility originally admitted the resident on 6/7/2024 and readmitted on [DATE] with diagnoses including type
two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound
healing), dependence on renal (kidney) dialysis, and end stage renal disease (ESRD-irreversible kidney
failure).
During a review of Resident 160's Minimum Data Set (MDS - a resident assessment tool) dated 4/1/2025,
the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor,
cues/supervision required). The MDS indicated that Resident 160 was dependent on staff (helper does all
of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, putting
on/taking off footwear, and personal hygiene. The MDS further indicated that Resident 160 was undergoing
hemodialysis while a resident in the facility.
During a review of Resident 160`s care plan (a document that outlines how a patient's health care needs
will be met) for hemodialysis initiated on 6/20/2024, the care plan indicated that the resident had right upper
chest quinton catheter. The care plan interventions were to monitor dialysis access site for sign and
symptoms of infection, bleeding, pain, clotting, swelling, drainage, and discoloration, and notify the
physician if it occurs.
During a review of Resident 160`s care plan for potential for unavoidable bleeding on the AV shunt site or
right upper chest central line initiated on 6/20/2024, the care plan indicated a goal that the risk of
occurrence of emergency bleeding will be reduced through interventions daily. The care plan interventions
were to document monitoring of dialysis site during every shift and as needed.
During a review of Resident 160`s admission assessment dated [DATE], the admission assessment
indicated that the resident had right upper chest quinton catheter for hemodialysis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 36 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0698
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Resident 160's physician Order Summary Report (physician orders) dated 3/26/2025,
the Order Summary Report indicated to place Resident 160 on fluid restriction and not place any water
pitcher at her bedside.
During a review of Resident 160`s care plan for fluid restriction initiated on 4/14/2025, the care plan
indicated a goal that the resident will not show any signs and symptoms of fluid overload. The care plan
interventions were to place no water pitcher at the resident`s bedside.
During a review of Resident 160's physician Order Summary Report dated 4/17/2025, the Order Summary
report indicated to monitor Resident 160`s right upper arm arteriovenous fistula (AVF- a connection that is
made between an artery and a vein for dialysis access) for bleeding, itching, pain, and swelling during
every shift.
During a review of Resident 160`s Medication Administration Records (MAR - a daily documentation record
used by a licensed nurse to document medications and treatments given to a resident) for
4/1/2025-4/31/2025 and 5/1/2025-5/8/2025, the MARs indicated no documentation of monitoring Resident
160`s right upper chest quinton catheter.
During an observation on 5/5/2025 at 9:20 a.m., inside Resident 160`s room, a written note on the wall on
top of the resident`s bed indicated No water pitcher at bedside. However, a full pitcher of water, a full glass
of milk and juice were observed on the resident`s side table. Resident 160 stated that she is undergoing
hemodialysis on Mondays, Wednesdays, and Fridays at noon. During an observation, a right upper chest
quinton catheter was observed with dressing.
During a concurrent observation and interview on 5/5/2025 at 9:21 a.m. with Infection Preventionist (IPN)
inside Resident 160 `s room, IPN stated that there was a full pitcher of water, a full glass of milk and juice
at the resident`s side table. IPN stated Resident 160 is undergoing hemodialysis, and her physician ordered
to place no water pitcher at her bedside. IPN stated the staff failed to follow Resident 160`s physician order
regarding fluid restrictions. IPN stated that the potential outcome is that Resident 160 may experience a
fluid overload.
During a concurrent interview and record review on 5/8/2025 at 11:45 a.m., with Registered Nurse 1 (RN
1), Resident 160`s physician orders, MARs and care plans were reviewed. RN 1 stated Resident 160 is
undergoing hemodialysis and her care plan indicated that she has right upper chest quinton catheter and
right upper arm AV fistula. However, she (RN 1) cannot find any physician orders for monitoring Resident
160`s right upper chest quinton catheter. RN 1 stated licensed staff did not implement Resident 160`s care
plan intervention and did not monitor the resident`s right chest quinton catheter. RN 1 stated licensed staff
are required to monitor residents` dialysis access sites. RN 1 stated the potential outcome of not monitoring
residents` dialysis access sites is infection and bleeding.
During an interview on 5/8/2025 at 3:18 p.m., with the Director of Nursing (DON), the DON stated that staff
are required to implement physician orders for the resident`s fluid restriction. The DON stated Resident 160
requires hemodialysis three times a week, and it is necessary to not place a water pitcher at her bedside as
ordered by her physician to prevent fluid overload and edema. The DON stated license staff failed to obtain
a physician order for monitoring Resident 160`s right chest quinton catheter and failed to monitor the
catheter as indicated in her care plan. The DON stated the potential outcome is infection and bleeding.
During a review of the facility`s Policy and Procedures (P&P) titled Care of Resident Receiving
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 37 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0698
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Renal Dialysis, last reviewed on 7/16/2024, the P&P indicated that if residents have a central line, assess
site for signs and symptoms of complications and notify the physician. The physician orders specific fluids
allowed in 24 hours. Fluid restriction limited to no water pitcher at bedside promises improved quality of life.
During a review of the facility`s Policy and Procedures (P&P) titled Fluid Restricted-Diet, last reviewed on
7/16/2024, the P&P indicated that when a resident requires fluid restriction, a physician`s order shall be
obtained and shall note the parameters of the fluid intake desires. Fluid restricted diet shall be monitored by
the nursing department. The nursing department shall remove water pitcher from resident`s bedside.
Event ID:
Facility ID:
056149
If continuation sheet
Page 38 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
Deficiency Text Not Available
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 39 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow its Patient Assessment, policy and procedure for one
sampled resident (Resident 18) reviewed under dementia care by failing to conduct a quarterly social
service assessment .
Residents Affected - Few
This deficient practice had the potential for Resident 18 to not attain or maintain the highest practicable
physical, mental and psychosocial health.
Findings:
During a review of Resident 18's admission Record, the admission Record indicated that the resident was
admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (is an
infection that inflames the air sacs [thin-walled structures composed of simple squamous epithelium] in one
or both lungs), Parkinsonism (a clinical syndrome characterized by a group of motor symptoms, including
bradykinesia[ slowed movement], rigidity[stiffness], and tremor, and often associated with impaired posture
and gait), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025,
the MDS indicated that the resident had severely impaired cognition (severely damaged mental abilities,
including remembering things, making decisions, concentrating, or learning).The MDS indicated that
Resident 18 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper
and lower body dressing, putting on/talking off footwear, and personal hygiene.
During a concurrent interview and record review on 5/8/2025 at 10:12 a.m., with the Social Service Director
(SSD), Resident 18`s assessments were reviewed. The SSD stated that social service assessment has to
be done quarterly and annually. However, she (SSD) did not conduct a quarterly social service assessment
in March 2025. The SSD stated that social service assessment includes psychosocial history, physical,
cultural and spiritual factors having impact on the resident`s adjustment and wellbeing in the facility, and the
determination of anticipated discharge planning. The SSD stated that the last social service assessment
was conducted on 1/13/2025. The SSD stated that the reason she did not conduct a social service
assessment for Resident 18 was because she was backed up with assignments for other residents. The
SSD stated that the potential outcome of not timely reassessing a resident is the delay in addressing their
psychosocial issues.
During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated the social
worker shall conduct a social service assessment every quarter and annually. The DON stated SSD did not
conduct quarterly social service assessment for Resident 18 in March 2025 and the potential outcome is
the inability to address psychosocial concerns and prevent psychosocial issues.
During review of the facility's Policy and Procedure (P&P) titled, Patient Assessments, last reviewed on
7/16/2024, the P&P indicated The resident assessment coordinator is responsible for ensuring that the
interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the
following requirements:
a. OBRA required assessments- conducted for all residents in the facility:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 40 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0745
1.admission Assessment
Level of Harm - Minimal harm
or potential for actual harm
2.Quaterly Assessments
3.Annual Assessments
Residents Affected - Few
4. Significant Change in Status Assessment
5.Significant Correction to prior Comprehensive Assessment
6. Significant Correction to prior Quarterly Assessment
7.Discharge Assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 41 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview, and record review the facility failed to:
1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1)
medication emergency kit (eKIT-contains certain medications that could be taken if needed immediately)
containing controlled medications (CM- medications which have a potential for abuse and may also lead to
physical or psychological dependence) for 5/2025, in one (1) of two (2) inspected medication rooms
(Medication Room Station 1).
2. Reconcile one (1) medication eKIT containing CMs for 5/2025, in one (1) of five (5) inspected medication
carts (Medication Cart Station 2B.)
These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication
or other medication from a lawful to an unlawful channel of distribution or use).
Findings:
During a concurrent observation and interview on 5/5/2025 at 12:50 p.m., with Registered Nurse 1 (RN 1)
and in the presence of the Director of Nursing (DON) in Medication Room Station 1, observed one (1)
medication eKIT in the refrigerator labeled 109 containing CMs without an accountability log for the
reconciliation of CM inventory at every shift for 5/2025. RN 1 stated that all CMs, including medication
eKITs containing CMs, should be reconciled at every shift. RN 1 stated that the eKIT labeled 109 containing
CMs in Medication Room Station 1 was not reconciled at every shift in 5/2025, and it was important to
account for all CMs to ensure accountability, prevent CM diversion, and accidental exposure of harmful
substances to residents. The DON stated the eKIT labeled 109 contained CMs and was not reconciled at
each shift for 5/2025. The DON stated that the facility will immediately implement an accountability log for
reconciliation of eKITs containing CMs at each shift in Medication Room Station 1.
During a concurrent observation and interview on 5/5/2025 at 2:15 p.m., with Licensed Vocational Nurse 1
(LVN 1), observed in Medication Cart Station 2B, one (1) medication eKIT labeled 318 containing CMs
without an accountability log for the reconciliation of CM inventory at every shift for 5/2025. LVN 1 stated
that the eKIT labeled 318 containing CMs in Medication Cart Station 2B was not reconciled at every shift in
5/2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion, and
accidental exposure of harmful substances to residents.
During an interview on 5/6/2025 at 12:28 p.m., with the DON, the DON stated that medication eKITs
containing CMs need to be counted and reconciled at every shift change to ensure accountability and
prevent CM diversion. The DON stated one (1) eKIT containing CMs in Medication Cart Station 2B was not
reconciled at each shift for 5/2025. The DON stated that the facility will immediately implement an
accountability log for reconciliation of eKITs with CMs at each shift change in Medication Cart Station 2B.
During a review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, last
reviewed 7/16/2024, the P&P indicated, Medications included in the Drug Enforcement Administration
(DEA) classification as controlled substances are subject to special handling, storage, disposal, and
recordkeeping in the facility, in accordance with federal and state laws and regulations. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 42 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0755
Level of Harm - Minimal harm
or potential for actual harm
DON and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and
regulations in the handling of CMs. At each shift change, a physical inventory of all CMs including the
emergency supply is conducted by two (2) licensed nurses and is documented on the CM accountability
record.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 43 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that its medication error rate was less
than five (5) percent (%). Two (2) medication errors out of 34 total opportunities contributed to an overall
medication error rate of 8.82% affecting two (2) of six (6) residents observed for medication administration
(Resident 151 and 183.) The medication errors were as follows:
Residents Affected - Some
1. Resident 151 received carvedilol (a medication used to for hypertension [HTN - a condition in which the
blood vessels have persistently raised pressure]) at a different time than ordered by Resident 151 ' s
physician.
2. Resident 183:
a. did not receive docusate (a medication used to soften stool) as ordered by Resident 183 ' s physician
b. received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins,
minerals, and other nutritional elements) that was different than the one ordered by Resident 183 ' s
physician
These failures had the potential to result in Resident 151 and 183 receiving suboptimal (less than standard)
care, experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may
have) and resulting in Residents 151's and 183's health and well-being negatively impacted.
Findings:
During an observation on 5/5/2025 at 9:10 a.m., in Medication Cart 1A, Registered Nurse 3(RN 3) was
observed administering multivitamin with minerals tablet orally and not administering docusate tablet to
Resident 183. Resident 183 was observed swallowing the multivitamin with mineral tablet with a glass of
juice.
During an interview on 5/5/2025 at 11:55 a.m., with RN 3, RN 3 stated the physician order for Resident 183
indicated to hold the docusate dose for loose stool. RN 3 stated RN 3 did not administer docusate to
Resident 183, during the morning medication administration at 9:10 a.m. since Resident 183 had a soft
stool that morning. RN 3 stated Resident 183 did not have loose stool, and the dose should not have been
held. RN 3 stated that not administering docusate could potentially harm Resident 183 by increasing the
risk of having hard stools and constipation.
During the same interview, RN 3 stated RN 3 stated the physician order for Resident 183 indicated to give
multivitamin not containing minerals. RN 3 stated RN 3 failed to administer the correct multivitamin as
prescribed by Resident 183's physician. RN 3 stated administering multivitamin with minerals to Resident
183 may not be beneficial to their health and may cause adverse effects. RN 3 stated these were
considered medication errors.
During an observation on 5/6/2025 at 10:05 a.m., in Medication Cart 2B, Licensed Vocational Nurse 1 (LVN
1) was observed administering carvedilol 6.25 milligram ([mg]-a unit of measure of mass) tablet orally to
Resident 151. Resident 151 was observed swallowing the carvedilol tablet with a glass of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 44 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0759
water.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/6/2025 at 11:40 a.m., with LVN 1, LVN 1 the physician order for Resident 151
indicated to administer carvedilol at 8 a.m. with food to prevent stomach discomfort. LVN 1 stated per facility
policy there was a 60-minute window for medication administration and LVN 1 administered carvedilol later
than that timeframe. LVN 1 stated LVN 1 failed to administer carvedilol as prescribed by Resident 151's
physician placing Resident 151 at risk of receiving the next dose closer in time and experiencing stomach
irritation. LVN 1 stated this was considered a medication error.
Residents Affected - Some
During an interview 5/6/2025 at 12:28 p.m., with the Director of Nursing (DON), the DON stated LVN 1
failed to administer carvedilol 6.25 mg tablet to Resident 151 according to physician orders at 8 a.m. that
(5/6/2025) morning. The DON stated RN 3 failed to administer multivitamin without minerals and docusate
to Resident 183, according to physician orders on 5/5/2025. The DON stated these were considered
medication errors. The DON stated Resident 151 may be at risk for having the next dose given in a shorter
timeframe since it was ordered to be given twice a day, and possible stomach irritation. The DON stated
Resident 183 may possibly experience constipation or hard stools by not receiving docusate and be at risk
of not being able to tolerate the additional minerals from the multivitamin. The DON stated licensed nurses
should follow facility medication administration guidelines to ensure physician orders are followed and the
right medications are administered at the right time to residents.
During a review of Resident 183's admission Record (a document containing demographic and diagnostic
information,) dated 5/5/2025, indicated Resident 183 was originally admitted to the facility on [DATE] with a
diagnosis including malnutrition (a condition when the body does not receive enough nutrients,) and failure
to thrive (to do well.)
During a review of Resident 183's Order Summary Report, dated 5/5/2025, the report indicated Resident
183 was prescribed:
1. docusate 100 mg to give one (1) tablet by mouth twice a day for stool softener [hold for loose bowel
movement], starting 4/1/2025
2. multivitamin to give one (1) tablet by mouth once a day for wound regimen, starting 4/9/2025
During a review of Resident 183's Medication Administration Record ([MAR] - a record of mediations
administered to residents), for May 2025, the MAR indicated Resident 183 was prescribed:
1. docusate 100 mg one (1) tablet by mouth twice a day for stool softener [hold for loose bowel movement],
to give at 9 a.m. and 6 p.m.
2. multivitamin one (1) tablet by mouth once a day for wound regimen, to give at 9 a.m.
During a review of Resident 151 ' s admission Record dated 5/6/2025, indicated Resident 151 was
originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including HTN.
During a review of Resident 151's Order Summary Report, dated 5/6/2025, indicated Resident 151 was
prescribed carvedilol 6.25 mg to give (1) tablet by mouth twice a day for HTN give with food, starting
4/9/2024.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 45 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of Resident 151's MAR for May 2025, the MAR indicated Resident 151 was prescribed
carvedilol 6.125 mg one (1) tablet by mouth twice a day for HTN give with food, to give at 8 a.m. and p.m.
During a review of the facility's policy and procedures (P&P) titled Medication Administration-General
Guidelines, last reviewed 7/16/2024, the P&P indicated that Medications are administered as prescribed in
accordance with good nursing principles and practices .
Preparation
3. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the
medication label.
Administration
2. Medications are administered in accordance with written orders of the attending physician.
10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after),
except before or after meals, which are administered based on mealtimes.
During a review of the facility's P&P, titled Adverse consequences and Medication Errors, last reviewed
7/16/2024, the P&P indicated:
1. An 'adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may
have . An adverse consequence may include:
a. Adverse drug/medication reaction
b. Side effect
2. The staff and practitioner shall strive to minimize adverse consequences by:
a. Following relevant clinical guidelines and manufacturer ' s specifications for use, dose, administration,
duration, and monitoring of the medication;
1. A medication error is defined as the preparation or administration of drugs or biological which is not in
accordance with physician ' s orders, manufacturer specifications, or accepted professional standards and
principles of the professional(s) providing services.
2. Examples of medication error include:
a. Omission - a drug is ordered but not administered;
f. Wrong drug
g. Wrong time.
During a review of the facility ' s document, titled Meals Serving Times, [undated], the document indicated:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 46 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0759
Breakfast - 7:30 to 8:30
Level of Harm - Minimal harm
or potential for actual harm
Lunch - 12:30 to 1:30
Dinner - 5:30 to 6:30
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 47 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to:
1. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels)
Aspart (short-acting insulin) Flexpen (an injection device containing insulin) for Resident 6, in accordance
with manufacturer ' s requirements and facility policy and procedures in one (1) of two (2) inspected
medication rooms (Medication Room Station 1.)
2. Label one (1) insulin Humulin R (long-acting insulin) vial for Resident 12, in accordance with
manufacturer's requirements and facility policy and procedures in one (1) of two (2) inspected medication
rooms (Medication Room Subacute.)
3. Remove and discard from use one (1) Procrit (brand name medication for epogen used to treat anemia
[having low red blood cells) vial for Resident 14, in accordance with manufacturer 's requirements and
facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room
Subacute.)
These deficient practices increased the risk that Residents 6, 12, and 14 could have received medication
that had become ineffective or toxic due to improper storage or labeling, possibly leading to health
complications resulting in hospitalization or death.
Findings:
During an observation on [DATE] at 12:26 p.m., in Medication Room Subacute, in the presence of
Registered Nurse 2 (RN 2), the following medications were found either stored in a manner contrary to their
respective manufacturer ' s requirements, not labeled with an open date as required by their respective
manufacturer ' s specifications, or stored and labeled contrary to facility policies:
1. One (1) opened insulin Humulin R multi-dose (containing more than one dose) vial for Resident 12 was
found stored in the refrigerator and without a label indicating when use first began, and an additional label
indicating to discard 31 days after opening
According to the manufacturer's product labeling, opened Humulin R vials should be stored at room
temperature below 86 degrees Fahrenheit and used or discarded after 31 days of opening.
2. One (1) opened single dose vial of Procrit for Resident 14 was found stored in the refrigerator containing
unused volume of medication, with a label indicating Single-dose Discard unused potion.
According to manufacturer's product storage and labeling, Procrit single-dose vials should be stored in the
refrigerator between 36 and 46 degrees Fahrenheit and once opened to be discarded.
During a concurrent interview with RN 2, RN 2 stated the Humulin R vial for Resident 12 opened, not
labeled with a date indicating when use began and stored in the refrigerator. RN 2 stated the opened
Humulin R vial should be stored at room temperature and once opened good for 31 days, after which the
insulin loses potency (effectiveness.) RN 2 stated the Humulin R vial for Resident 12 was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 48 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
considered expired since it was not stored correctly and unaware of the date the vial was opened. RN 2
stated administering expired insulin error to Resident 12 will not be effective in keeping the blood sugar
stable and can harm Resident 12 by causing high blood sugar levels leading to coma (a state of deep
unconsciousness caused by severe injury or illness), Diabetic Ketoacidosis ([DKA] - a condition that
develops when the body doesn ' t have enough insulin resulting in the buildup of acid in the blood to levels
that can be life threatening], hospitalization or death. RN 2 stated the Humulin R vial for Resident 12
needed to be removed from the refrigerator, disposed of and replaced with a new one from pharmacy.
During the same interview, RN 2 stated the Procrit vial for Resident 14 was used with some volume of
medication remining in the vial and continued to be stored in the refrigerator. RN 2 stated the Procrit vial for
Resident 14 was considered expired since it was opened and used, and continued storage in the
refrigerator
created the potential for accidental use. RN 2 stated expired Procrit vial has decreased medication potency
and when used in error could be ineffective by not treating or controlling Resident 14's anemia, requiring
additional treatments. RN 2 stated the Procrit vial for Resident 14 needed to be removed from the
refrigerator and disposed of to prevent accidental use.
During an observation on [DATE] at 12:50 p.m., in Medication Room Station 1, in the presence of RN 1, the
following medications were found either stored in a manner contrary to their respective manufacturer's
requirements, not labeled with an open date as required by their respective manufacturer's specifications,
or stored and labeled contrary to facility policies:
1. One (1) open insulin Aspart Flexpen for Resident 6 was found stored in the refrigerator with a label
indicating that use began on [DATE], and an additional label indicating to discard 28 days after opening.
According to the manufacturer's product labeling, opened Aspart Flexpen should be stored at room
temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening.
During a concurrent interview with RN 1, RN 1 stated the insulin Aspart Flexpen for Resident 6 was opened
on [DATE] and stored in the refrigerator. RN 1 stated expired insulin has lost its potency and administering
expired insulin Aspart to Resident 6 will not be effective in keeping the blood sugar stable and can harm
Resident 6 by causing high blood sugar levels leading to DKA and hospitalization. RN 1 stated according to
the label the pen expired after 28 days on [DATE] and needed to be removed from the refrigerator and
medication room to not be used in error and replaced with a new pen from pharmacy.
During an interview on [DATE] at 12:28 p.m., with the Director of Nursing (DON), the DON stated that
multi-dose medications like insulin vials and pens should be labeled with a date open label and discarded
after 28 days from that date. The DON stated insulin vials with no date open label are considered expired
and should not be used, and insulin pens that have expired needed to be removed from use. The DON
stated expired insulin has lost its effectiveness and should be discarded to prevent accidental use. The
DON stated that administering expired insulin in error will not be effective in controlling blood sugar levels
and can harm
Residents 6 and 12 by causing high or low blood sugar levels, leading to emergency crisis and requiring
hospitalizations. The DON stated that unlabeled and expired insulins needed to be removed from
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 49 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0761
the refrigerator and replaced immediately with new ones from pharmacy.
Level of Harm - Minimal harm
or potential for actual harm
During the same interview, the DON stated single-use vials that have been used immediately expire and
should be disposed to prevent accidental use. The DON stated that administering expired Procrit in error
will not be effective and can harm Resident 14 by not treating the anemia. The DON stated the Procrit vial
needed to be removed from refrigerator and disposed of to prevent accidental use. The DON stated several
licensed nurses failed to dispose of single dose Procrit vial from the refrigerator.
Residents Affected - Some
During a review of facility's policy and procedures (P&P,) titled Storage of Medications, last reviewed on
[DATE], the P&P indicated that Medications and biologicals ae stored safely, and properly, following
manufacturer ' s recommendations or those of the supplier.
J. Medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees
Fahrenheit to 86 degrees Fahrenheit.
M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of
according to procedures for medication disposal, and reordered from pharmacy if a current order exist.
During a review of facility's P&P titled Procedures for All Medications, last reviewed on [DATE], the P&P
indicated: To administer medications in a safe and effective manner.
E. Check expiration date on package/container. When opening a multi-dose container, place the date on the
container.
N. Once removed from the package or container, unused doses should be disposed of in accordance with
the medication destruction policy.
During a review of facility's P&P titled, Vials and Ampules of Injectable Medications, last reviewed [DATE],
the P&P indicated: Vials and ampules of injectable medications are used in accordance with the
manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal.
B. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials.
C. Ampules and single-dose vials are discarded immediately after use.
E. Medication in multi-dose vials may be used until manufacturer ' s expiration date or 6 months after
opening unless otherwise specified. Refer to Guide for Special Handling of Medications.
During a review of facility's P&P, titled Guide for Special Handling of Medications, last reviewed [DATE], the
P&P listed the following:
Multiple Dose Vials for injection - Discard 28 days after opening
Single Dose vial - Discard after initial use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 50 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to prepare food by methods that
conserved temperature, flavor and appearance when the temperature of the food were as follows:
Residents Affected - Some
-Zest spinach 121 degrees Fahrenheit (°F, a scale of temperature)
-Chocolate cake 60°F,
-Milk 47°F and 49°F
-Puree chocolate cake 57°F.
This deficient practice placed 138 of 199 facility residents on regular, therapeutic diets (a meal plan that
controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at
risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.
Findings:
During a review of the facility'' daily spreadsheet (a list of food, amount of food that each diet would receive)
titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on Regular and therapeutic
diet t would include the following foods on the tray:
-Meat balls with gravy 2 pieces 1-2 ounces (oz, a unit of measurement)
-Gravy 1 oz
-Penne with garlic and herbs ½ cup (c., household measurement
-Zesty spinach ½ c.
-Fresh green salad with dressing ½ c
-Chocolate cake 2x2 ½ inches
-Milk 4 oz
During a review of the facility's menu spreadsheet titled Spring Cycle Menus, dated 5/6/2025, the
spreadsheet indicated residents on puree diet would include the following foods on the tray:
-Puree meatballs 2- number 16 scoops (1/2 c total)
-Gravy 1 oz
-Puree penne with garlic and herbs ½ c.
-Puree zesty spinach 1/3 c.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 51 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0804
-Puree fresh green salad with dressing 1/3 c.
Level of Harm - Minimal harm
or potential for actual harm
-Puree chocolate cake 1/3 c.
-Milk 4 fluid oz.
Residents Affected - Some
During a concurrent observation on 5/6/2025 at 11:45 a.m. in the trayline (an area where foods were
assembled from the steamtable to resident's plate) area with [NAME] 1, observed [NAME] 1 taking
temperatures of the hot and cold food. [NAME] 1 stated the green salad was 54.8°F. [NAME] 1 stated
he had to put it back in the freezer before serving.
During a concurrent observation on 5/6/2025 at 12:11 p.m. in the trayline area with [NAME] 1, observed
[NAME] 1 took the temperature the green salad from the freezer. [NAME] 1 stated the green salad
temperature was at 50°F and the chocolate cake with icing was at 54.9°F.
During an observation on 5/6/2025 at 12:42 p.m. in the trayline area, observed a rack of chocolate cake and
milk were out in room temperature.
During an observation on 5/6/2025 at 12:48 p.m. of [NAME] 3, [NAME] 3 cooked extra zesty spinach and
directly poured it in the steamtable pans without taking the temperature of the spinach.
During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation
and interview on 5/6/2025 at 1:29 p.m. of the regular test tray with the Dietary Supervisor (DS), observed
and the DS stated zesty spinach was at 121°F, chocolate cake with icing at 60 °F and milk was at
49°F when the DS took the temperature of the food using the facility thermometer.
During a concurrent test tray observation and interview on 5/6/2025 at 1:35 with the DS, observed the
following temperature when the DS took the food temperatures using the facility thermometer:
-Milk 49°F
-Puree chocolate cake 57°F
During an interview on 5/6/2025 at 1:56 p.m. with the DS, the DS stated cold food temperatures could be
better as they follow a standard of below 41°F and hot food should be above 135°F. The DS
stated hot food should be hot and cold food should be cold. The DS stated zesty spinach at 121°F,
chocolate cake of 60°F and milk at 49°F was not okay as the residents expected cold food to be
cold and hot food to be hot. The DS stated residents could potentially get food borne illnesses, they might
not eat and result in weight loss.
During an interview on 5/7/2025 at 12:02 p.m. with [NAME] 3, [NAME] 3 stated she prepared the spinach
for yesterday's lunch, and she forgot to take the temperature. [NAME] 3 stated it was important to take the
temperature of the food to ensure safety and if it was still cold, it would not be good as bacteria could grow
making the residents sick.
During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 7/16/2024, the
P&P indicated Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional
value. Procedure: (1) All foods will be prepared by methods that preserve nutritive
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 52 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0804
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
value, flavor and appearance and will be attractively served at the proper temperature and in a form to meet
the individual needs of the residents. (9) Food temperatures will be taken to ensure all hot foods are at a
proper serving temperature. Food temperature will be recorded daily. (10) Hold foods prior to service for as
short time as possible. Food should not be held more than two hours during service. Hot food should be
held prior to service at 140°F for above and cold foods at 40°F or below. Keep food covered
during holding.
During a review of the facility's P&P titled Meal Service reviewed 7/16/2024, the P&P indicated, (2) Food
temperatures will be taken to ensure all hot foods are at a proper serving temperature. Food temperature
will be recorded daily. Food items:
-Vegetables, fruits, grains at least 135°F
-Cold beverages, desserts no more than 40°F.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 53 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to
meet individual needs when puree (foods that are smooth with pudding like consistency) when puree pasta
was sticky pasta and not smooth pudding like consistency.
These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and
nutrient intake to 18 of 18 residents on puree diet, resulting in unintended (not planned) weight loss and
chocking (when food gets stuck in your airway, blocking the flow of air to your lungs).
Findings:
During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each
diet would receive) titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on
puree diet would include the following foods on the tray:
-Puree meatballs 2- number 16 scoops (1/2 c total)
-Gravy 1 oz
-Puree penne with garlic and herbs ½ c.
-Puree zesty spinach 1/3 c.
-Puree fresh green salad with dressing 1/3 c.
-Puree chocolate cake 1/3 c.
-Milk 4 fluid oz.
During a concurrent observation and interview on 5/6/2025 at 11:15 a.m. of puree pasta preparation with
[NAME] 1, observed [NAME] 1 pouring potato flakes to the puree pasta without measuring it. [NAME] 1
stated he used potato flakes as a thickener, and he would know it was in the right consistency by following
the recipe and using a spoon tilt test.
During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation
and interview on 5/6/2025 at 1:35 p.m. with the Dietary Supervisor (DS) and the Registered Dietitian (RD),
observed little pasta particles on the puree pasta. The RD stated puree diet should be smooth, no lumps,
not sticky but not too watery. The DS stated the puree pasta was sticky and would involve more chewing.
The DS stated residents on puree diet could aspirate and had trouble chewing and swallowing as a
potential outcome of not achieving correct puree texture and consistency. The DS stated the proper way to
prepare puree food was to follow the recipes by measuring the correct ingredients to achieve texture and
consistency.
During a review of the facility's policies and procedures (P&P) titled Diet Orders reviewed 7/16/2024, the
P&P indicated POLICY: The physician will prescribe diets in accordance with the approved Diet Manual.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 54 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed
and avoided and sample menus the facility have) titled Regular Pureed Diet reviewed 7/16/2024, the diet
manual indicated The pureed diet is a regular diet that has been designed for residents who have difficulty
chewing and/or swallowing. The texture of the food should be smooth and moist consistency and able to
hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are
normally in a soft, and smooth state such as pudding, ice cream, applesauce, mashed potato, etc.
During a review of the facility's P&P titled Menu reviewed 7/16/2024, the P&P indicated, Procedure: Menus
are planned to meet the Recommended Dietary Allowances of the Food and Nutrition Board, National
Research Council, adjusted to the age, activity and environment of the group involved. (5) The menus will
be prepared as written using standardized recipes.
During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Starch (Rice,
Pasta, Polenta, Potatoes, etc.), the recipe indicated ingredients: (48 servings) starch per recipe: 48
servings, warm milk 48 to 96 oz, instant potato 1 ½ - 3 cups). The finished pureed item should be
smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The
finished pureed item must pass the IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure and
spoon tilt tests).
During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated,
Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to
hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method:
Spoon tilt test and fork drip test.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 55 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food
storage and food preparation practices in the kitchen when:
Residents Affected - Some
1.
Opened plastic bags of frozen pancakes and frozen pie crust in the freezer were not labeled and dated.
2.
Kitchen equipment and kitchen areas were not cleaned and sanitized.
a.
The reach-in refrigerator's ceiling had dust and dirt debris.
b.
The two drawers by the preparation area were dirty to touch and had dust buildup.
c.
Plate warmer's internal part where the clean plates were stored had food and white dirt debris.
d.
The two push carts where clean resident's trays, bases and domes were stored had dirt, food and hair
debris.
e.
Condiment containers contain loose sugar, pepper, sweetener particles and dirt residues.
3.
Kitchen equipment and utensils were not maintained in their proper condition, smooth and easy to clean.
a.
Seven (7) of 7 green shelves in the Walk-in Refrigerators 1 and 2 had cracks, chips, and rust with amber
discoloration.
b.
The green chopping board had black and brown stains and scratches.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 56 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
c.
Level of Harm - Minimal harm
or potential for actual harm
The juice rack had rust.
4.
Residents Affected - Some
Three (3) staff (two cooks and one dietary aide) were wearing wristwatches, a bracelet and a diamond ring
while preparing food.
5.
Five (5) of 5 dented were stored with non-dented cans.
6.
Gray, clear food containers, plates and resident's trays were stacked wet with water particles.
7.
There was no separation between the dirty area (trash can in the handwashing area) and the clean bowl
storage area.
8.
Staff was wearing nail polish while cooking food.
9.
The residents' freezer in Station 1 had no thermometer.
These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of
harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by
consuming food or drinks that are contaminated by germs or chemicals) in 138 of 199 medically
compromised residents who received food and ice from the kitchen.
Findings:
1. During an initial kitchen tour on 5/5/2025 at 8:20 a.m., with the Dietary Supervisor (DS), in the walk-in
freezer a bag of opened frozen pancakes containing six individual pancakes and a bag of opened frozen
pie crusts containing three pie crusts were observed without a label and date of when they were opened.
The DS stated that frozen food taken from original packaging in the freezer should be labeled and dated to
ensure they will be used first. The DS stated the potential outcome of not dating the opened packages of
food is the inability to determine how long the items were stored in the freezer.
During review of the facility`s Policy and Procedure (P&P) titled Refrigerator/Frezer Storage, last reviewed
on 7/16/2024, the P&P indicated that leftover food or unused portions of packaged foods should be
covered, dated and labeled to ensure they will be used first. All items should be properly covered, dated,
and labeled. Food items should have the following appropriate dates: Delivery date
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 57 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
(upon receipt), Open date (opened container of PHF) and Thaw date (any frozen item). Frozen food taken
from the original packaging should be labeled and dated. Food that has freezer burns should be discarded.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.17
Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section,
refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food
processing plant shall be clearly marked, at the time the original container is opened in a food
establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food
shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations
specified in (A) of this section and (1) The day the original container is opened in the food establishment
shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a
manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.
2. a. During an observation on 5/6/2025 at 8:30 a.m., of the reach-in refrigerator by the handwashing
station, observed dust on the ceiling.
During an interview on 5/6/2025 at 8:35 a.m. with the DS, the DS stated the refrigerator ceiling was dusty,
and staff missed cleaning the ceiling. The DS stated it was not okay that the walk-in refrigerator was dusty
due to cross-contamination of dust to food that could potentially get the residents sick of diarrhea, vomiting
and stomachache.
During a review of the facility's P&P titled Refrigerator and Freezer, reviewed 7/16/2024, the P&P indicated,
(17) The refrigerator and freezer area will be clean and dry, well-ventilated at all times.
b. During an observation on 5/7/2025 at 11:18 a.m. of the preparation area, observed two drawers where
food containers and sandwich bags were stored had dust buildup.
During an interview on 5/7/2025 at 11:31 a.m. with the DS, the DS stated the drawer was deep cleaned
once a week however, staff cleaned it every day. The DS stated the drawers had dust build up and staff did
not clean last night. The DS stated it was important to keep the drawers clean to avoid food borne illnesses
for the residents.
c. During an observation on 5/7/2025 at 11:24 a.m. of the plate warmer, observed the internal parts of the
plate warmer had dust and dirt debris.
During a concurrent observation and interview on 5/72/2025 at 11:53 a.m. of the plate warmer with the DS,
the DS stated the plate warmer internal parts had white spill dirt and it was noticeable. The DS stated it was
not okay due to cross-contamination of food. The DS stated the plates had also water particles and were
not air dried.
d. During an observation on 5/7/2025 at 11:29 a.m. of the pushcart used to store resident's tray, observed
the pushcart had dust and dirt debris.
During an observation on 5/7/2025 at 11:30 a.m. of the pushcart used to store dome and lids, observed the
pushcart had dust and dirt debris.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 58 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
Level of Harm - Minimal harm
or potential for actual harm
During a concurrent observation and interview on 5/7/2025 at 11:45 a.m. of the two pushcarts by the
trayline (an area where foods were assembled from the steamtable to resident's plate) with the DS, the DS
stated the two pushcarts used to store resident's tray, domes and base were a clean area, however it had
dirt, food and hair debris. The DS stated the pushcarts were not cleaned yesterday and it was not okay as it
could potentially contaminate food items in trayline.
Residents Affected - Some
e. During a concurrent observation and interview on 5/7/2025 at 11:49 a.m. of the condiment container with
the DS, observed the condiment containers had loose sugar, pepper, sweetener particles and dirt. The DS
stated the condiment containers were not clean yesterday and it needed to be cleaned to prevent
cross-contamination of food potentially causing food borne illness to the residents.
During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, reviewed 7/16/2024, the P&P
indicated, Sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as
needed.
During a review of the facility's P&P titled Cleaning Schedule, reviewed 7/16/2024, the P&P indicated, All
areas and equipment in the kitchen should be cleaned daily. The assigned dietary personnel will deep clean
the area equipment assigned for them that day using the dietary cleaning schedule.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A)
Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this
section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2)
Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between
uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or
storing a food temperature measuring device, and (5) At the time during the operation when contamination
may have occurred.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13
Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency
necessary to preclude accumulation of soil residues.
3. a. During an observation on 5/6/2025 at 8:42 a.m. of the green racks in walk-in refrigerator 1, observed
three (3) of 3 green racks had cracks and chips.
During an observation on 5/6/2025 at 8:49 a.m. of the green racks in the walk-in refrigerator 2, observed
four (4) of 4 green racks had cracks, chips with amber discoloration.
During an interview on 5/6/2025 at 8:59 a.m. with the DS, the DS stated the green racks in the walk-in
refrigerators were rusted and they needed to be in good condition with no hips and rust as it could
potentially make the residents sick of food borne illnesses.
b. During an observation on 5/7/2025 at 11:14 a.m. of the white chopping board, observed the white
chopping board had black dirt stains and scratches.
During an interview on 5/7/2025 at 11:37 a.m. with the DS, the DS stated the chopping board should be
free from noticeable scratch because it would not be properly washed or sanitized, and food particles could
get stuck in it. The DS stated the white chopping boards were considered as green chopping boards and it
had black and brown stains and scratches. The DS stated the fruit could potentially be contaminated if the
chopping boards had scratches and stains.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 59 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's P&P titled Cutting Board Cleaning reviewed 7/16/2024, the P&P indicated,
All cutting boards should be clean and in good condition.
c. During an observation on 5/7/2025 at 11:26 a.m. of the juice dispenser rack by the trayline, observed
rack was rusted.
Residents Affected - Some
During a concurrent observation and interview on 5/7/2025 at 11:43 a.m. of the juice rack with the DS, the
DS stated the juice rack looked rusty and he needed to contact the company to replace it as it was not
acceptable in the kitchen due to cross-contamination of the food.
During a review of the facility's P&P titled Sanitizing Equipment and Surfaces reviewed 7/16/2024, the P&P
indicated (6) Dietary staff should ensure that all equipment, shelves, serving utensils, and surface areas
are clean and in good condition.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11
Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open
seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners,
and crevices, (4) Finished to have smooth welds and joints.
4. During an observation on 5/6/2025 at 8:56 a.m., of the trayline, observed [NAME] 1 was wearing a black
wristwatch and Dietary Aide 3 (DA 3) was wearing a silver bracelet while dishing out food from the
steamtable to the resident's plate.
During an observation on 5/6/2025 at 11:00 a.m. of the cold food preparation, observed [NAME] 2 wearing
a wristwatch and diamond ring while preparing cold food.
During an observation on 5/6/2025 at 11:08 a.m. of the cold food preparation, observed DA 3 was wearing
a silver bracelet while preparing dessert.
During an interview on 5/6/2025 at 12:43 p.m. with the DS, the DS stated jewelry was not allowed in the
kitchen due to infection control purposes for the residents.
During a review of the facility's P&P titled Sanitation and Infection Control, reviewed 7/16/2024, the P&P
indicated (9) No dangling jewelry or earrings should be worn. Only wedding rings are acceptable.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition.
Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry
including medical information jewelry on their arms and hands.
5. During an observation on 5/6/2025 at 9:15 a.m. in the dry storeroom, observed two (2) dented cans
stored with non-dented cans.
During a concurrent observation and interview on 5/6/2025 at 9:23 a.m. of the dry storeroom with the DS,
observed three (3) dented cans stored with non-dented cans from the emergency food supply. The DS
stated a separate area of dented cans was designated so the staff would not accidentally use them. The
DS stated there were four (4) dented cans stored with non-dented cans and it was not okay as it could
cause physical contamination of food resulting in potential food borne illnesses to the residents who would
consume it.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 60 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of the facility's P&P titled Storage of Canned and Dry Goods, reviewed 7/16/2024, the P&P
indicated (10) Canned items should be inspected for damage such as dented, leaking or bulging cans.
These items will be stored separately in the designated area- Dented Cans for return to the vendor or
disposed of properly.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe
Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under
3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that
food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of
which are discussed below. However, it is also critical to monitor food products to ensure that, after
harvesting, processing, they do not fail victims to conditions that endanger their safety, make them
adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers
should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of
abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated
and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted,
and pitted or dented cans may also present a serious potential hazard.
6. During an observation on 5/6/2025 at 11:11 a.m. of the food container storage area, gray bins and clear
Cambro containers were stacked wet.
During an interview on 5/6/2025 at 12:50 p.m. with the DS, the DS stated the process of dishwashing was
to wash, rinse, sanitize, then air dry. The DS stated the food containers were staked wet and it was not okay
as there were still water particles. The DS stated it was important to airdry dishes to avoid moist that could
grow bacteria resulting in food borne illnesses.
During a review of the facility's P&P titled Manual Dishwashing-2-3 Compartment Sink, reviewed 7/16/2025,
the P&P indicated, (6) Dishes should be allowed to air dry before storage.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment
and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried
or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions
for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing
solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been
air-dried may be polished with cloths that are maintained clean and dry.
7. During an observation on 5/6/2025 at 11:36 a.m. of the garbage can by the bowl storage area, water
splashes observed from handwashing area to the bowl storage area.
During an interview on 5/6/2025 at 12:46 p.m. with the DS, the DS stated the bowl storage was a clean
area, but it was near the handwashing sink trash can and it was not okay. The DS stated there was no
separation of clean and dirty areas that could cause food contamination.
During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, reviewed 7/16/2024, the P&P
indicated, To prevent cross-contamination and ensure food safety by maintaining strict separation between
clean a dirty area within the dietary department. (8) Dietary staff to ensure clean and dirty areas shall be
separated by physical barriers where possible workflows must be designated to ensure that the clean and
dirty processes do not overlap in time or space.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 61 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-307.11
Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from
a factor or source not specified under subparts 3-391 - 3-306.
8. During an observation on 5/6/2025 at 11:42 a.m. of lunch food preparation, observed [NAME] 3 wearing
a turquoise nail polish while cooking food for lunch.
During an interview on 5/6/2025 at 1:04 p.m. with the DS, the DS stated staff were not allowed to wear nail
polish due to physical contamination as the nail polish could fall in the food. The DS stated [NAME] 3 was
wearing nail polish and it was not allowed.
During a review of the facility's P&P titled Sanitation and Infection Control, reviewed 7/16/2024, the P&P
indicated (3) Fingernails should be clean, clipped and free of nail polish.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, (A) Food employees
shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not
rough. (B) Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or
artificial fingernails when working with exposed food.
9. During a concurrent observation and interview on 5/7/2025 at 3:51 p.m. of the resident's freezer in
Station 1 with Licensed Vocational Nurse 4 (LVN 4), the resident's freezer had no thermometer to monitor
the temperature. LVN 4 stated the freezer was not monitored and the temperature log also did not indicate
that they were monitoring the freezer temperatures. LVN 4 stated it was important to monitor the freezer to
prevent food spoilage and expiration.
During an interview on 5/7/2025 at 4:03 p.m. with the Registered Nurse Supervisor (RNS), the RNS stated
it was important to monitor the freezer temperature as they did not want the food items to get bad. The RNS
stated residents could potentially get sick of food poisoning when consuming food that was not in
acceptable temperatures.
During a review of the facility's P&P titled Refrigerator/Freezer Storage, reviewed on 7/16/2024, the P&P
indicated Dietary staff will check the inside temperature of refrigerators and freezers to ensure the
equipment is within appropriate temperature for food storage and handling. (1) Dietary staff will check and
record temperatures of all refrigerators and freezers to ensure the equipment is within appropriate
temperature for food storage and handling. (2) Dietary staff will record the initial temperature log at the
beginning of the shift. (3) If the temperatures are not within appropriate range, dietary staff will notify the
dietary supervisor and or Maintenance Supervisor and Administrator. Freezer temperature: 0-degree
Fahrenheit (°F, a scale of temperature) or lower.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112
Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of
a Temperature Measuring Device shall be located to measure the air temperature or a simulated product
temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food
storage unit. (B) Except as specified in (C) of this section, cold or hot holding equipment used for
time/temperature control for safety food shall be designed to include and shall be equipped with at least
one integral or permanently affixed temperature measuring device that is located to allow easy viewing of
the device's temperature display.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 62 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to dispose garbage and refuse
properly when there were soiled gloves, empty plastic bottles, plastic and other trash on the floor and
surrounding areas of the dumpster bin (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).
Residents Affected - Some
This failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 138 of 199
facility residents.
Findings:
During a concurrent observation and interview on 5/7/2025 at 3:10 p.m. of the dumpster with the Dietary
Supervisor (DS), observed soiled gloves, empty bottles, plastic and other trash on the ground. The DS
stated it was not okay to have trash around the dumpster surroundings because it could attract pests, and
could spread sickness to the residents. The DS stated he did not know who maintains the trash area.
During an interview on 5/7/2025 at 4:11 p.m. with the Maintenance Director (MD), the MD stated he
maintains the dumpster and trash area and it needed to be cleaned to prevent flies, rats and animals
around. The MD stated it was not okay that there was trash around the dumpster surroundings. The MD
stated this could spread diseases to residents as a potential outcome.
During a review of the facility's policies and procedures (P&P) titled Waste Control and Disposal dated
7/16/2024, the P&P indicated All waste will be disposed of daily and as needed throughout the day. (6)
Outside garbage bin should be kept closed at all times and surrounding area must be kept clean,
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning
Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the
development of odors, prevent such waste from becoming an attractant and harborage of breeding place
for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly
handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source
of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting
lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry
of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper
cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 63 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide a Physical Therapy ([PT] profession
aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation to one of
seven sampled residents (Resident 690) with range of motion ([ROM] full movement potential of a joint
[where two bones meet]) and mobility (ability to move) concerns in accordance with the physician's order,
dated 5/1/2025.
Residents Affected - Few
This deficient practice prevented Resident 690 from receiving a PT Evaluation to assess the possibility of
receiving additional therapy to achieve Resident 690's goal of walking with a single point cane ([SPC]
walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to
provide support while walking) to return home.
Findings:
During a review of Resident 690's admission Record, the admission Record indicated the facility admitted
Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges
(three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic
intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop
(condition where the individual experiences difficulty or inability to lift their foot or toes) of both feet, and
reduced mobility.
During a review of Resident 690's Minimum Data Set (MDS- a resident assessment tool), dated 4/29/2025,
the MDS indicated Resident 690 had clear speech, expressed ideas and wants, clearly understood verbal
content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS
indicated Resident 690 required setup or clean up assistance for eating, partial/moderate assistance
(helper does less than half the effort) for rolling to either side in bed, and dependent for toileting, bathing,
dressing, and putting on/taking off footwear.
During a review of Resident 690's PT Evaluation and Plan of Treatment, dated 4/19/2025, the PT
Evaluation indicated Resident 690's prior level of function (ability prior to admission to the facility) was
independent with rolling to both sides of the bed, transferring from lying to sitting at the edge of the bed,
transferring from sitting to standing, and walking using a SPC. The PT Evaluation indicated Resident 690's
goal was to return to walking with the SPC. The PT Evaluation indicated Resident 690's current ability (as of
4/19/2025) was dependent (helper does all the effort, resident does none of the effort to complete the
activity) with rolling to both sides of the bed and dependent with two-person assistance for transferring from
lying to sitting at the edge of the bed. The PT Evaluation also indicated that sit-to-stand transfers were not
attempted due to medical conditions or safety concerns. The PT Plan of Treatment included therapeutic
activity (tasks that improve the ability to perform activities of daily living [(ADLs- tasks related to personal
care including bathing, dressing, hygiene, eating, and mobility]), therapeutic exercises (movement
prescribed to correct impairments and restore muscle function), neuromuscular re-education (technique
used to restore movement patterns through repetitive motion to retrain the brain), orthotic management (the
process of designing, making, fitting, and training patients in the use of orthoses [material used to restrict,
protect, or immobilize a part of the body to support function, assist and/or increase range of motion]), and
wheelchair management training (training on proper positioning and ability to propel the wheelchair), six
times per week for four weeks. The PT Plan of Treatment was signed by Physician 1's (MD 1's) nurse
practitioner ([NP] nurse who is qualified to treat certain medical conditions without the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 64 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0825
direct supervision of a doctor) on 4/21/2025.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 690's PT Discharge summary, dated [DATE], the PT Discharge Summary
indicated Resident 690 was dependent with rolling to both sides and dependent with two-person assistance
for transferring from lying to sitting on the side of the bed. Resident 690's PT Discharge Summary indicated
the reason for discharge was in accordance with the physician or case manager. The PT Discharge
recommendations included restorative nursing assistant (RNA - an ongoing program that focuses on
helping individuals, especially those in long-term care, maintain and improve their functional abilities and
independence, often following rehabilitation) to provide Resident 690 with active assistive range of motion
([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a
person or equipment) to both arms and passive range of motion ([PROM] movement of a joint through the
ROM with no effort from person) to both legs, seven times per week as tolerated. The PT Discharge
recommendations also included RNA to apply both pressure relief ankle foot orthoses ([PRAFO] device
worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to
Resident 690's ankles for two to four hours or as tolerated, seven times per week.
Residents Affected - Few
During a review of Resident 690's physician's order, dated 4/22/2025, the physician's order indicated RNA
for AAROM to both arms and PROM to both legs. Another physician's order, dated 4/23/2025, indicated for
the RNA to apply both PRAFOs for two to four hours or as tolerated, seven times per week.
During a review of Resident 690's care plan titled, Self care deficits, initiated 4/29/2025, the care plan
interventions included Rehabilitation (therapy given to restore an individual back to their highest possible
level of physical, mental, and psychosocial well-being) as ordered.
During a review of Resident 690's physician's order, dated 5/1/2025, the physician's order indicated PT
Evaluation and Treatment when authorized under Medicare Part B (federal medical insurance for persons at
least [AGE] years old that covers certain services).
During a review of Resident 690's Licensed Nursing Progress Note, dated 5/1/2025 by Registered Nurse 4
(RN 4), the Licensed Nursing Progress Note indicated MD 1 approved the PT Evaluation in accordance
with Resident 690's request when authorized under Medicare Part B. The Licensed Nursing Progress Note
indicated Resident 690's physician's order was given to the case manager for authorization.
During a review of Resident 690's Physical Therapy Note, dated 5/6/2025, the Physical Therapy Note
indicated the RNA (unspecified) reported improvement with minimally active movement in the right leg. The
Physical Therapy Note indicated the RNA program was changed from PROM to AAROM on the right leg.
During a review of Resident 690's physician's order, dated 5/6/2025, the physician's order indicated to
discontinue PROM to both legs due to the RNA's reports of improvement in the right leg. The physician's
order, dated 5/6/2025, indicated for the RNA to provide Resident 690 AAROM to both arms and the right
leg and PROM to the left leg.
During an interview on 5/6/2025 at 9:12 a.m., with the Director of Rehabilitation (DOR), the DOR stated the
purpose of PT included to improve a resident's mobility, including improving strength, the ability to get out of
bed, and the ability to walk, to enhance their independence if possible.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 65 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent observation and interview on 5/6/2025 at 11:27 a.m., with Resident 690 in the
resident's room, Resident 690 was awake, alert, and spoke with clear, fluent speech while lying in bed with
the head-of-bed elevated. Resident 690 stated she underwent brain surgery three times and walked with a
SPC due to left leg weakness after the second brain surgery and prior to the third surgery in 2/2025.
Resident 690 stated the hospital discharged Resident 690 to another nursing facility after brain surgery due
to Resident 690's inability to move both legs, including the right leg. Resident 690 stated PT and
Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating
in everyday life activities [occupations]) provided therapy services at the previous nursing facility. Resident
690 stated she was transferred from the previous nursing facility to the current facility due to safety
concerns and to receive more therapy services. Resident 690 stated she spoke with the DOR and worked
with Physical Therapist 1 (PT 1) on the first Saturday of admission [DATE]) but did not receive any PT
treatment afterward. Resident 690 stated both arms moved well and movement was starting to return to the
right leg. Resident 690 was observed without any ROM limitations in both arms. Resident 690 could slowly
lift the right leg upward at the hip joint, slowly bent the right knee, and slightly bent the right ankle toward
the body. Resident 690 stated RN 4 asked MD 1 for a PT Evaluation last week and was waiting for the DOR
to approve it. Resident 690 expressed feelings of anger and frustration because the facility staff does a
disappearing act around here especially when it comes to my therapy. Resident 690 stated she wanted to
return home after receiving therapy. Resident 690 stated the RNAs provided exercises daily. Resident 690
stated the staff used a mechanical lift to transfer Resident 690 into a Geri chair (reclining chair that allows
someone to get out of bed and sit comfortably in different positions while fully supported) daily since
Resident 690 did not have a wheelchair.
During an observation on 5/6/2025 at 1:45 p.m., with Restorative Nursing Assistant 1 (RNA 1) in Resident
690's room, observed Resident 690's RNA session. RNA 1 stood on the left side of Resident 690's bed to
perform PROM on the left leg at the hip, knee, and ankle joints. RNA 1 walked to the right side of the bed to
perform AAROM of the right leg. Resident 690 was observed lifting the right leg at the hip joint (hip flexion),
requiring RNA 1's assistance to lift the right leg higher. Resident 690 was observed moving the right hip into
abduction (moving the leg at the hip joint away from the body), requiring RNA 1's assistance to move the
right legs further away from the body. Resident 690 slid the right leg at the hip joint back toward the body
(hip adduction) without physical assistance. Resident 690 slightly bent and extended the right knee,
requiring RNA 1's physical assistance to completely bend and extend the knee. Resident 690 also moved
the right ankle toward the body (dorsiflexion) and away from the body (plantarflexion), requiring RNA 1's
physical assistance to fully move at the ankle joint.
During an interview on 5/6/2025 at 2:18 p.m., with RNA 1, RNA 1 stated Resident 690 was seen for PROM
of the left leg and AAROM of both arms and the right leg. RNA 1 stated Resident 690 did ROM exercises to
both arms without much physical assistance. RNA 1 stated she reported Resident 690's desire for more
therapy services to PT 1. RNA 1 stated PT 1 saw Resident 690 today (5/6/2025) and changed the RNA
order from PROM to AAROM on the right leg.
During a concurrent interview and record review on 5/7/2025 at 2:47 p.m., with the DOR, reviewed
Resident 690's PT Evaluation, dated 4/19/2025, and PT Discharge summary, dated [DATE]. The DOR
stated the facility admitted Resident 690 on 4/18/2025 from another nursing facility. The DOR stated the
facility was aware Resident 690's health insurance had provided a last covered date (last date the person's
health insurance policy covered specific services) of 4/21/2025 for therapy services prior to Resident 690's
admission to the facility. The DOR stated PT 1 completed Resident 690's PT Evaluation on 4/19/2025 and
recommended treatment six times per week for four
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 66 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
weeks. The DOR stated Resident 690 was discharged from PT on 4/21/2025 in accordance with the health
insurance's last covered date. The DOR stated the PT Discharge recommendations included an RNA
program to provide Resident 690 with PROM to both legs and application of both PRAFOs.
During an interview on 5/7/2025 at 3:06 p.m., with PT 1, PT 1 stated RNA 1 reported an improvement in
movement to Resident 690's right leg yesterday (5/6/2025). PT 1 stated Resident 690's RNA program was
modified from PROM to AAROM exercises to the right leg.
During an interview on 5/7/2025 at 3:47 p.m., with the DOR, the DOR stated she did not speak with MD 1
about Resident 690's therapy services. The DOR stated the facility was waiting for authorization from
Resident 690's health insurance to provide PT services.
During an interview on 5/7/2025 at 3:53 p.m., with the Case Manager (CM), the CM stated the Medicare
Managed Health Plan (private company contracted with Medicare to provide health care and services)
provided a last covered date for Resident 690's therapy services prior to Resident 690's admission to the
facility. The CM stated the previous facility issued Resident 690 a Notice of Medicare Non-Coverage
([NOMNC] form used by Medicare providers to notify beneficiaries when Medicare-covered services are
ending) and stated the facility did not receive a copy of Resident 690's issued NOMNC.
During an interview on 5/7/2025 at 4:07 p.m., with the CM and Resident 690, Resident 690 stated she did
not have a Medicare Managed Health Plan.
During a concurrent interview and record review on 5/7/2025 at 4:30 p.m., with Licensed Vocational Nurse
3 (LVN 3) and the DOR, reviewed Resident 690's physician order, dated 5/1/2025. LVN 3 stated the
physician was contacted and physician's order was submitted based on the conversation with the physician
if a resident (in general) was requesting more therapy services. LVN 3 stated Resident 690's physician
order, dated 5/1/2025, indicated PT Evaluation and Treatment when authorized under Medicare Part B. LVN
3 stated the PT was supposed to carry out the physician's order. The DOR stated Resident 690's
physician's order for PT Evaluation and Treatment was sent to the CM for authorization.
During an interview on 5/7/2025 at 4:37 p.m., with the CM, the CM stated Resident 690 did not have
Medicare. The CM stated Resident 690's health insurance provided the last covered date for therapy
services. The CM stated Resident 690's physician order, dated 5/1/2025, for PT Evaluation and Treatment
was sent to the health insurance for review.
During an interview on 5/8/2025 at 10:56 a.m., with the Social Services Director (SSD), the SSD stated
Resident 690's discharge plan included receiving therapy and returning home.
During an interview on 5/8/2025 at 11:57 a.m., with the CM, the CM stated Resident 609's physician order,
dated 5/1/2025, for PT Evaluation was submitted to Resident 690's health insurance on 5/7/2025 at 4:01
p.m. The CM stated Resident 690's physician's order was not submitted to the health insurance on 5/1/2025
because the CM did not work from 5/2/2025 to 5/4/2025 and was catching up on other work from 5/5/2025
to 5/6/2025.
During a telephone interview on 5/8/2025 at 12:18 p.m., with MD 1, MD 1 stated Resident 690 had left leg
weakness and walked with a cane prior to brain surgery. MD 1 stated Resident 690 requested a PT
Evaluation on 5/1/2025 and wrote orders for a PT Evaluation to determine if Resident 690 could benefit
from more therapy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 67 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent interview and record review on 5/8/2025 at 1:52 p.m., with the DOR, reviewed
Resident 690's physician's order, dated 5/1/2025, and the facility's policy and procedure (P&P) titled,
Rehabilitation Services. The DOR stated Resident 60's physician's order indicated PT Evaluation and
Treatment when authorized under Medicare Part B. The DOR stated Resident 690 did not have Medicare
and did not receive a PT Evaluation since the health insurance has not authorized the service. The DOR
reviewed the facility's P&P and stated the P&P did not indicate to perform the PT Evaluation after receiving
authorization from the resident's health insurance. The DOR stated Resident 690 did not receive a PT
Evaluation within 48 hours in accordance with the facility's P&P.
During a concurrent interview and record review on 5/8/2025 at 2:09 p.m with the Administrator (ADM),
reviewed Resident 690's physician's order, dated 5/1/2025, and the facility's P&P titled, Rehabilitation
Services. The ADM stated the PT would have evaluated Resident 690 if the physician's order did not
specifically indicate when authorized under (Medicare) Part B. The ADM reviewed the facility's P&P titled,
Rehabilitation Services, and stated the P&P did not indicate to wait for an authorization prior to performing
a PT evaluation.
During a review of the facility's undated P&P titled, Rehabilitation Services, the P&P indicated Skilled
rehabilitation services shall be made available to resident in order to promote recovery, improve and
maintain functional independence, and prevent any further decline. The P&P indicted rehabilitation services
require specific orders from the attending physician to be written in the resident's health record. The P&P
indicated the therapy evaluation orders shall be address within 48 hours.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 68 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on observation, interview, and record review, the facility failed to ensure the Restorative Nursing
Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility)
records for one of seven sampled residents (Resident 690) with limitation in range of motion ([ROM] full
movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated the provision
of passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to
both legs from 4/22/2025 to 5/5/2025 in accordance with the physician's order, dated 4/22/2025. This failure
resulted in the inaccurate provision of care recorded in Resident 690's medical records.
Findings:
During a review of Resident 690's admission Record, the admission Record indicated the facility admitted
Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges
(three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic
intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop
(condition where the individual experiences difficulty or inability to lift their foot or toes) of both feet, and
reduced mobility.
During a review of Resident 690's physician's order, dated 4/22/2025, the physician's order indicated RNA
for active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise
but requires some help from a person or equipment) to both arms and PROM to both legs.
During a review of Resident 690's Documentation Survey Report (record of nursing tasks) for 4/2025, the
Documentation Survey Report indicated the RNA provided AAROM to both arms and the right leg and
PROM to the left leg from 4/22/2025 to 4/30/2025.
During a review of the Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated
4/29/2025, the MDS indicated Resident 690 had clear speech, expressed ideas and wants, clearly
understood verbal content, and had intact cognition (clear ability to think, understand, learn, and
remember). The MDS indicated Resident 690 required setup or clean up assistance for eating,
partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and
dependent for toileting, bathing, dressing, and putting on/taking off footwear.
During a review of Resident 690's physician's order, dated 5/6/2025, the physician's order indicated to
discontinue PROM to both legs due to the RNA's reports of improvement in the right leg. The physician's
order, dated 5/6/2025, indicated for the RNA to provide Resident 690 AAROM to both arms and the right
leg and PROM to the left leg.
During a review of Resident 690's Documentation Survey Report for 5/2025, the Documentation Survey
Report indicated the RNA provided AAROM to both arms and the right leg and PROM to the left leg from
5/1/2025 to 5/7/2025.
During an observation on 5/6/2025 at 1:45 p.m. in Resident 690's room, Resident 690's RNA session was
observed. Restorative Nursing Assistant 1 (RNA 1) stood on the left side of Resident 690's bed to perform
PROM on the left leg at the hip, knee, and ankle joints. RNA 1 walked to the right side of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 69 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
the bed to perform AAROM of the right leg. Resident 690 was observed lifting the right leg at the hip joint
(hip flexion), requiring RNA 1's assistance to lift the right leg higher. Resident 690 was observed moving the
right hip into abduction (moving the leg at the hip joint away from the body), requiring RNA 1's assistance to
move the right legs further away from the body. Resident 690 slid the right leg at the hip joint back toward
the body (hip adduction) without physical assistance. Resident 690 slightly bent the right knee, requiring
RNA 1's physical assistance to completely bend the knee. Resident 690 also moved the right ankle toward
the body (dorsiflexion) and away from the body (plantarflexion), requiring RNA 1's physical assistance to
fully move at the ankle joint.
During an interview on 5/6/2025 at 2:18 p.m. with RNA 1, RNA 1 stated Resident 690 was seen for PROM
of the left leg and AAROM of both arms and the right leg. RNA 1 stated Resident 690 did ROM exercises to
both arms without much physical assistance. RNA 1 stated she reported Resident 690's desire for more
therapy services to Physical Therapist 1 ([PT 1] professional aimed in the restoration, maintenance, and
promotion of optimal physical function). RNA 1 stated PT 1 saw Resident 690 today (5/6/2025) and
changed the RNA order from PROM to AAROM on the right leg.
During an interview on 5/7/2025 at 3:06 p.m. with PT 1, PT 1 stated RNA 1 reported an improvement in
movement to Resident 690's right leg yesterday (5/6/2025). PT 1 stated Resident 690's RNA program was
modified from PROM to AAROM exercises to the right leg.
During a concurrent interview and record review on 5/8/2025 at 1:02 p.m. with the Director of Medical
Records (DMR), Resident 690's physician's orders for RNA, dated 4/22/2025 and 5/6/2025, and the
Documentation Survey Report, dated 4/2025 and 5/2025, were reviewed. The DMR stated Resident 690's
physician's order, dated 4/22/2025, indicated RNA to provide AAROM on both arms and PROM on both
legs, seven days per week, and was discontinued on 5/6/2025. The DMR stated Resident 690's physician's
order, dated 5/6/2025, indicated RNA to provide AAROM to both arms and the right leg and PROM to the
left leg, seven days per week. The DMR stated the Documentation Survey Report for RNA indicated
whether Resident 690 received RNA services. The DMR reviewed Resident 690's Documentation Survey
Report, dated 4/2025 and 5/2025, and stated the RNA services provided in the Documentation Survey
Reports from 4/22/2025 to 5/5/2025 did not reflect Resident 690's physician's order, dated 4/22/2025. The
DMR stated the Documentation Survey Report was inaccurate and indicated the RNA did not provide the
treatment in accordance with the physician's orders.
During an interview on 5/8/2025 at 3:18 p.m. and 5/8/2025 at 3:35 p.m. with the DMR, the DMR stated the
facility did not have a policy and procedure for medical record accuracy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 70 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 - Few
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.
Based on interview and record review, the facility failed to provide appropriate hospice services (a program
that gives special care to people who are near the end of life and have stopped treatment to cure or control
their disease) to one of one sampled resident (Resident 61) reviewed under Hospice and End of Life care
area by failing to:
1. Designate a member of the facility's interdisciplinary team to coordinate care provided to the residents by
the facility and the hospice company in their Hospice Program, policy.
2. Honor Resident 61`s Responsible Party 2`s (RP 2) wish to end the resident`s hospice services.
These deficient practices had the potential to negatively affect Resident 61`s physical comfort and
psychosocial well-being.
Findings:
During a review of Resident 61's admission Record (face sheet), the admission Record indicated that the
facility admitted the resident on 4/22/2024, with diagnoses including history of falling, muscle weakness,
cerebrovascular disease (conditions that affect blood flow to your brain), seizure (a sudden, uncontrolled
electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of
consciousness) and encounter for palliative care (specialized medical care for individuals with serious
illnesses that focuses on relieving symptoms, managing stress, and improving quality of life for both the
patient and their family).
During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2025, the
MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor,
cues/supervision required). The MDS indicated that Resident 61 was dependent on staff (helper does all of
the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting
on/taking off footwear, and personal hygiene. The MDS further indicated that Resident 61 was receiving
hospice care while a resident in the facility.
During a review of Resident 61`s physician Order Summary Report (physician order) dated 4/22/2024, the
Order Summary Report indicated to admit Resident 61 to Hospice Agency 1 (HA1) with primary diagnosis
of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). The order summary
report further indicated to call HA1 for any changes in the resident`s condition.
During a review of Resident 61`s care plan (a document outlining a detailed approach to care customized
to an individual resident's need) for expected deterioration (becoming worse) due to terminal illness (a
medical condition that is considered incurable and will eventually lead to death) initiated on 5/2/2024, the
care plan indicated that Resident 61 was under HA1 care for diagnosis of CVA. The care plan interventions
were to respect resident`s and or his family`s wishes, provide support and allow the resident to verbalize
his feelings.
During a record review of HA 1`s Attendance Flow Sheet for Registered Nurse (RN), the flow sheet
indicated that HA 1`s RN last visited Resident 61 in the facility on 5/5/2025 at 1:00 p.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 71 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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
During a record review of HA 1`s Attendance Flow Sheet for Licensed Vocational Nurse (LVN), the flow
sheet indicated that HA 1`s LVN last visited Resident 61 in the facility on 5/6/2025 at 5:00 p.m.
During a record review of HA 1`s Attendance Flow Sheet for Certified Home Health Aide (CHHA), the flow
sheet indicated that HA 1`s CHHA last visited Resident 61 in the facility on 5/6/2025 at 2:00 p.m.
Residents Affected - Few
During a concurrent interview and record review on 5/8/2025 at 9:48 a.m., with the Social Service Director
(SSD), Resident 61`s physician orders and SS notes were reviewed. The SSD stated that Resident 61 was
discharged from hospice services on 5/4/2025 per his Responsible Party 2`s (RP 2) request. The SSD
stated that she (SSD) is not sure why Resident 61 is still under HA 1 services. The SSD stated that she
called HA 1 and informed the owner that Resident 61`s RP 2 did not wish for Resident 61 to receive
hospice services anymore. The SSD stated that she (SSD) did not document her conversation with RP 2 to
discontinue Resident 61`s hospice services in the resident`s medical record. The SSD stated she did not
document her conversation with HA 1 to end the hospice services in Resident 61`s medical record. The
SSD stated HA1`s RN last visited Resident 61 on 5/5/2025. The SSD stated HA 1`s LVN and CHHA last
visited the resident on 5/6/2025 after RP 2 made the request to end the hospice services on 5/4/2025. The
SSD stated that she should have documented in Resident 61`s medical record about the conversationsshe
had with RP 2. The SSD also stated that she should have informed the physician and the facility`s
administration regarding RP 2`s request to end the hospice services for Resident 61. Thge SSD stated
Resident 61 is still under HA 1 care and hospice continues to receive payments for services they are
providing despite RP 2`s request to end hospice services. The SSD further stated that she is the
designated staff member to coordinate the care provided to residents by the facility staff and the hospice
staff. The SSD stated the facility`s policy titled Hospice Program, does not indicate her name as a
designated member. The SSD stated she failed to perform her responsibility as the coordinator of care
between the facility and HA 1. The SSD stated the potential outcome of not coordinating Resident 61's care
with the hospice provider is not honoring residents` wishes and not providing appropriate care.
During a telephone interview on 5/8/2025 at 11:56 a.m., with the DON of HA 1 (HDON), HDON stated that
they (HA 1) did not receive any calls from the SSD informing them to end Resident 61`s hospice services.
During a telephone interview on 5/8/2025 at 12:10 p.m., with Responsible Party 2 (RP 2), RP 2 stated that
she does not want Resident 61 to receive hospice care and services in the facility anymore. RP 2 stated
that last week on 5/1/2025 and 5/2/2025, she contacted the SSD and requested to discontinue Resident
61`s hospice services. RP 2 stated that she wants to transfer Resident 61 to a facility closer to where she
lives. RP 2 stated if Resident 61 continues to receive hospice care, the transfer will not happen.
During an interview on 5/8/2025 at 3:22 p.m., with the Director of Nursing (DON), the DON stated that the
SSD is the designated staff member to coordinate care provided to residents under hospice services by the
facility staff and the hospice staff. The DON stated the facility`s Hospice Program policy did not indicate the
SSD`s name as a designated staff member for coordination, and it should have. The DON stated the SSD
did not communicate with HA 1 and the facility staff regarding RP 2's wish to discontinue Resident 61`s
hospice services. The DON stated the facility respects all residents and their family members' wishes to
receive or discontinue the services the facility provides. The DON stated it is important to honor the
resident's wishes to ensure appropriate care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 72 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During a review of the facility`s Policy and Procedures (P&P) titled Hospice Program, last reviewed on
7/16/2024, the P&P did not indicate who is the designated person to coordinate care provided to the
resident by the facility staff and the hospice staff. This individual is responsible for the following:
Communicating with hospice representatives and other healthcare providers participating in the provision of
care for the terminal illness, related conditions to ensure quality of care for the resident and family, ensuring
that our facility staff provides orientation on the policies and procedures of the facility, including resident
rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the
residents.
Event ID:
Facility ID:
056149
If continuation sheet
Page 73 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to implement infection control practices by failing
to:
Residents Affected - Some
1. Implement Enhanced Barrier Precautions ([EBP] an infection control intervention in nursing homes
designed to reduce transmission of bacteria and other microorganisms that have developed resistance to
antibiotics making infections hard to treat) with Resident 130 and 151 in the therapy gym during high
contact activities.
This deficient practice had the potential to increase the risk of spreading infection to other residents.
2. Clean two of two cloth gait belts (assistive device placed around a person's waist to assist with safe
transferring between surfaces or while walking) used with Resident 151 in accordance with the
manufacturer's recommendations for disinfecting wipes (pre-moistened towelettes that contain a sanitizing
or disinfecting formula that kill or reduce germs on surfaces).
This deficient practice had the potential for cross contamination and placed the residents at risk of
acquiring an infection.
3. To ensure a resident's oxygen tubing (a flexible tube that delivers supplemental oxygen from an oxygen
concentrator or other oxygen supply to a device like a nasal cannula or mask) was not touching the floor for
one (Resident 174) out of six sampled residents investigated under the care area of infection control.
This deficient practice had the potential to place the resident at increased risk of developing an infection.
4. Maintain infection control practices by failing to ensure a urine bottle (a container for receiving urine) was
not hung and stored on a trash can full of trash for one of one sampled resident (Resident 113) during a
random observation.
This deficient practice had the potential for cross contamination and placed the residents at risk of
acquiring an infection.
5. Ensure foam bed rail padding was free from rips and gouges and could be properly cleaned and
disinfected for three of five sampled residents (Residents 182, 642, and 643).
This deficient practice had the potential for cross contamination and placed the residents at risk of
acquiring an infection.
6. Keep the floor of a storage room clean, ensure employees' personal items were not placed on top of
boxes containing medical supplies, and ensure boxes of medical supplies were stored off of the floor.
These deficient practices had the potential to transmit infectious microorganisms to residents in the facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 74 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Findings:
Level of Harm - Minimal harm
or potential for actual harm
1. During a review of Resident 130's admission Record, the admission Record indicated the facility
originally admitted Resident 130 on 11/16/2023 and re-admitted on [DATE] with diagnoses including
hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following a cerebral
infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, attention to
tracheostomy (hole fitted with a device through the front of the neck and into the windpipe [trachea] to allow
air into the lungs), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow
feedings to be administered directly to the stomach common for people with swallowing problems).
Residents Affected - Some
During a review of Resident 130's care plan titled, Enhanced Barrier Precaution, initiated 6/6/2024, the care
plan interventions included to provide EBP with gloves, gowns, and masks.
During an observation on 5/6/2025 at 10:09 a.m. in the therapy gym, Resident 130 was seated in a
wheelchair with a portable oxygen tank attached to the back of the wheelchair seat. Resident 130 had
oxygen flowing into the tracheostomy tube.
During an observation on 5/7/2025 at 11:25 a.m. in the therapy gym, Resident 130 walked using a
height-adjustable four-wheeled walker (an assistive device with four wheels used for stability when walking)
with a padded platform underneath the forearms. The Director of Rehabilitation (DOR) and Certified
Occupational Therapy Assistant 1 (COTA 1) were on each side of Resident 130 while walking. The DOR
and COTA 1 were not wearing any gowns.
During an observation on 5/8/2025 at 9:23 a.m. outside of Resident 130's room, there was a sticker labeled
E next to Resident 130's name.
During an interview on 5/8/2025 at 9:24 a.m. with Registered Nurse 5 (RN 5) outside of Resident 130's
room, RN 5 stated the sticker labeled E next to the resident's name indicated the resident was on
Enhanced Barrier Precautions (EBP) because the resident has a tracheostomy tube and prone to infection.
RN 5 stated anyone coming into high contact with the residents on EBP needed to wear a gown and gloves
to protect the residents from infection and to prevent the spread of infection to the healthcare workers.
During an interview on 5/8/2025 at 10:05 a.m. with COTA 1, COTA 1 stated Resident 130's treatment
session in the therapy gym yesterday (5/7/2025) included range of motion ([ROM] full movement potential
of a joint) exercises. COTA 1 stated Resident 130 required physical assistance of two-persons to perform
sit-to-stand transfers during the treatment and walked with assistance while using the height-adjustable
four-wheeled walker.
2. During a review of Resident 151's admission Record, the admission Record indicated the facility
admitted Resident 151 on 3/21/2024 with diagnoses including cerebral infarction due to occlusion
(blockage) or stenosis (narrowing) of the right anterior cerebral artery (blood vessels delivering oxygen rich
blood to the front and middle parts of the brain), attention to tracheostomy, attention to gastrostomy, and
contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of the right elbow,
right hand, and both ankles.
During a review of Resident 151's care plan titled, Enhanced Barrier Precaution, initiated 4/9/2025, the care
plan interventions included to provide EBP with gloves, gowns, and masks.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 75 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Level of Harm - Minimal harm
or potential for actual harm
During a concurrent observation and interview on 5/6/2025 at 1:05 p.m. in Resident 151's room, Resident
151 was awake and lying in bed with a bandage over the resident's throat in the front of the neck.
During an interview on 5/6/2025 at 3:18 p.m. in the bedroom, Resident 151 stated the tracheostomy tube
was removed three weeks ago.
Residents Affected - Some
During an observation on 5/7/2025 at 10:33 a.m. in the therapy gym, Resident 151's Physical Therapy ([PT]
profession aimed in the restoration, maintenance, and promotion of optimal physical function) session was
observed. Resident 151's bandage over the throat did not fully cover the hole in the front of Resident 151's
neck. Resident 151 was sitting up in a Geri chair (reclining chair that allows someone to get out of bed and
sit comfortably in different positions while fully supported). Physical Therapist 1 (PT 1) placed a cloth gait
belt around Resident 151's waist and placed a height-adjustable four-wheeled walker in front of Resident
151. PT 1 stood directly next to Resident 151 on the left side while the DOR stood directly on the right side
to physically assist Resident 151 with transferring from sitting to standing with the four-wheeled walker.
Resident 151 attempted to walk with PT 1 and the DOR while both forearms were supported on a padded
platform attached to the four-wheeled walker. PT 1 and the DOR were not wearing any gowns. Resident
151 sat up in a wheelchair at the end of the session.
During an observation on 5/7/2025 at 11:13 a.m., PT 1 and Rehabilitation Aide 1 (RA 1) wheeled Resident
151 back to the bedroom. PT 1 and RA 1 put on gowns and gloves prior to entering Resident 151's
bedroom. PT 1 placed the cloth gait belt around Resident 151's waist. PT 1 and RA 1 physically assisted
Resident 151 to transfer from the wheelchair to the edge of the bed. PT 1 removed the cloth gait belt from
around Resident 151's waist and assisted the resident back into the bed.
During an observation on 5/8/2025 at 9:28 a.m. outside of Resident 151's room, there was a sticker labeled
E next to Resident 151's name.
During an interview on 5/8/2025 at 9:29 a.m. with Registered Nurse 1 (RN 1) outside of Resident 151's
room, RN 6 stated the sticker labeled E next to the resident's name indicated the resident was on
Enhanced Barrier Precautions and stated a gown and gloves needed to be worn while handling Resident
151. RN 1 stated Resident 151 was on EBP because there was an open hole in the throat from Resident
151's recent removal of the tracheostomy tube.
During an interview on 5/8/2025 at 9:43 a.m. with PT 1, PT 1 stated Resident 151 was on EBP only inside
the resident's room. PT 1 stated EBP were extra precautions for residents with G-tubes and oxygen to
prevent infection. PT 1 stated it would be better to wear a gown while providing therapy to Resident 151 in
the therapy gym.
During a concurrent interview and record review on 5/8/2025 at 9:48 a.m. with the Infection Prevention
Nurse (IPN), the facility's P&P titled, Enhanced Barrier Precautions, dated 6/5/2024, was reviewed. The IPN
stated residents with EBP were at high-risk of infection and included residents with tracheostomy tubes,
G-tubes, and open wounds. The IPN stated personal protective equipment ([PPE] clothing and equipment
that is worn or used to provide protection against hazardous substances and/or environments) including
gowns and gloves were worn during high contact care, including transfers. The IPN stated therapists
working with residents while transferring was a high contact activity and should be wearing gowns and
gloves.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 76 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Level of Harm - Minimal harm
or potential for actual harm
During a review of the Center for Disease Control and Prevention (CDC) Frequently Asked Questions
(FAQs) about Enhanced Barrier Precautions in Nursing Homes
(https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html), dated 6/28/2024, the CDC FAQs
indicated EBP should be followed outside resident's rooms when working with residents in the therapy gym,
specifically when anticipating close physical contact while assisting with transfers and mobility.
Residents Affected - Some
2. During a review of Resident 151's admission Record, the admission Record indicated the facility
admitted Resident 151 on 3/21/2024 with diagnoses including cerebral infarction due to occlusion
(blockage) or stenosis (narrowing) of the right anterior cerebral artery (blood vessels delivering oxygen rich
blood to the front and middle parts of the brain), attention to tracheostomy (hole fitted with a device through
the front of the neck and into the windpipe [trachea] to allow air into the lungs), attention to gastrostomy
([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach
common for people with swallowing problems), and contractures (a stiffening/shortening at any joint that
reduces the joint's range of motion) of the right elbow, right hand, and both ankles.
During an observation on 5/6/2025 at 1:12 p.m., RNA 1 wore a cloth gait belt around the waist with RNA 1's
name written in black lettering.
During an observation on 5/6/2025 at 2:38 p.m. in Resident 151's room, RNA 1 and RNA 2 physically
assisted Resident 151 to transfer from lying in the bed to sitting at the edge of the bed. RNA 1 removed the
cloth gait belt from around RNA 1's waist and fastened it around Resident 151's waist. RNA 1 stood directly
next to Resident 151's right side while RNA 2 stood on the left side to physically assist Resident 151 from
sitting at the edge of the bed to standing using a height-adjustable four-wheeled walker (an assistive device
with four wheels used for stability when walking). RNA 2 removed the cloth gait belt from around Resident
151's waist after finishing with sit-to-stand exercises. RNA 1 and RNA 2 assisted Resident 151 back to lying
in bed. RNA 2 placed the cloth gait belt on top of Resident 151's dresser drawers.
During a concurrent observation and interview on 5/6/2025 at 3:11 p.m., RNA 1 removed the cloth gait from
the top of Resident 151's dresser drawers. RNA 1 stated disinfecting wipes were used to clean the cloth
gait belt and four-wheeled walker. RNA 1 was observed cleaning the cloth gait belt with disinfecting wipes.
During an observation on 5/7/2025 at 10:33 a.m. in the therapy gym, Resident 151's Physical Therapy ([PT]
profession aimed in the restoration, maintenance, and promotion of optimal physical function) session was
observed. Resident 151 was sitting up in a Geri chair (reclining chair that allows someone to get out of bed
and sit comfortably in different positions while fully supported). Physical Therapist 1 (PT 1) placed a cloth
gait belt with PT 1's name in black lettering around Resident 151's waist. PT 1 also placed a
height-adjustable four-wheeled walker in front of Resident 151. PT 1 stood directly on Resident 151's left
side while the Director of Rehabilitation (DOR) stood on the right side to assist Resident 151 with
transferring from sitting to standing with the four-wheeled walker. Resident 151 attempted to walk with PT 1
and the DOR while both forearms were supported on a padded platform attached to the four-wheeled
walker. Resident 151 sat up in a wheelchair at the end of the session. PT 1 removed the cloth gait belt from
around Resident 151's waist, rolled it up, and placed it in PT 1's left coat pocket.
During an observation on 5/7/2025 at 11:13 a.m., PT 1 and Rehabilitation Aide 1 (RA 1) wheeled Resident
151 back to the bedroom. PT 1 placed the cloth gait belt around Resident 151's waist. PT 1 and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 77 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Level of Harm - Minimal harm
or potential for actual harm
RA 1 physically assisted Resident 151 to transfer from the wheelchair to the edge of the bed. PT 1 removed
the cloth gait belt from around Resident 151's waist and assisted the resident back into the bed.
During a concurrent observation and interview on 5/7/2025 at 11:18 a.m., PT 1 placed the cloth gait belt
inside PT 1's left coat pocket. PT 1 stated disinfecting wipes were used to clean the cloth gait belt.
Residents Affected - Some
During a review of the undated manufacturer's recommendations of the disinfecting wipes, the
manufacturer's recommendations indicated it was a violation of Federal law to use the product inconsistent
with its labeling. The manufacturer's recommendations indicated the disinfecting wipes were for use on
hard, non-porous surfaces of non-critical medical devices.
During a concurrent observation, interview, and review of the disinfectant wipes' manufacturer
recommendations on 5/7/2025 at 4:17 p.m. with the Infection Prevention Nurse (IPN), the IPN stated the
disinfectant wipes' manufacture recommendations indicated for use on hard, non-porous surfaces. IPN
stated cloth was an example of a porous surface. The IPN observed PT 1's gait belt and stated it was made
of thick cloth. The IPN stated the disinfecting wipes were not effective in cleaning cloth gait belts. The IPN
stated there was a possibility of bacteria and germs spreading without proper cleaning of cloth gait belts.
During a review of the facility Policy and Procedure (P&P) titled, Cleaning and Disinfecting Non-Critical
Resident-Care Items, revised 4/2023, the P&P indicated the manufacturer's instructions will be followed for
proper use of disinfecting products, including material compatibility (ability of two or more materials to
perform effectively together).
During a review the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated
6/5/2024, the P&P indicated EBP was utilized to prevent the spread of multi-drug-resistant organisms
([MDROs] bacteria and other microorganisms that have developed resistance to antibiotics making
infections hard to treat) to residents. The P&P indicated EBP employed targeted gown and glove use during
high contact resident care activities, including during transfers.
3. During a review of Resident 174's admission Record, the admission Record indicated the facility
admitted the resident on 1/11/2025 with diagnoses including acute respiratory failure (occurs when the
lungs are unable to efficiently transfer oxygen into the blood, or remove carbon dioxide from the blood,
leading to a deficiency in oxygen and/or a buildup of carbon dioxide) and encounter for attention to
tracheostomy (a surgical procedure that creates an opening in the front of the neck [trachea] and inserts a
tube to provide a direct airway for breathing).
During a review of Resident 174's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025,
the MDS indicated the resident had severely impaired cognition (thought processes) and was dependent on
staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person
performs daily).
On 5/6/2025 at 9:30 a.m., during an observation, observed Resident 174 asleep in bed. The resident's
oxygen tubing was touching the floor.
On 5/6/2025 at 9:38 a.m., during a concurrent observation and interview with the Subacute Director (SD),
the SD verified that Resident 174's oxygen tubing was touching the floor. The SD stated that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 78 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
residents' oxygen tubing should be kept off the floor.
Level of Harm - Minimal harm
or potential for actual harm
On 5/8/2025 at 11:18 a.m., during an interview with the Director of Nursing (DON), the DON stated if a
resident's oxygen tubing was touching the floor, then the resident can potentially develop an infection.
Residents Affected - Some
During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on
7/16/2024, the policy and procedure indicated that oxygen tubing should be used in a manner that prevents
it from touching the floor.
4. During a review of Resident 113's admission Record, the admission Record indicated that the facility
initially admitted Resident 113 on 12/7/2023 and readmitted on [DATE] with diagnoses including but not
limited to encephalopathy (a group of conditions that cause brain dysfunction), type 2 diabetes (DM-a
disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling and
weakness.
During a review of Resident 113's History and Physical (H&P), dated 6/9/2024, the H&P indicated Resident
113 did have the capacity to understand and make decisions.
During a review of Resident 113's Minimum Data Set (MDS - a federally mandated resident assessment
tool), dated 2/21/2025, the MDS indicated that the resident had intact cognition (undamaged mental
abilities, including remembering things, making decisions, concentrating, or learning). The MDS further
indicated that Resident 113 was dependent on staff with oral hygiene and required set-up assistance for
other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to
thrive).
During concurrent observation and interview on 5/5/2025 at 10:43 am, in Resident 113's room, Resident
113 was lying in bed and had his urinal hanging inside his trash can and the trash can had food and paper
trash in it. Resident 113 stated he hangs it there because he does not have another place to hang it.
During concurrent observation and interview on 5/5/2025 at 10:45 am, in Resident 113's room with
Certified Nursing Assistant 5 (CNA 5), CNA 5 stated Resident 113 should not have his urinal in the trash
because the trash is dirty and the resident can get an infection. CNA 5 then asked Resident 113 if he had a
urinal holder and that she will get him one if he did not.
During an interview on 5/8/2025 at 1:48 pm with the Director of Nursing (DON), the DON stated staff must
empty the urinals as soon as they can and hang it in the urinal holders. The DON stated urinals must never
be stored on or in the trash can because it is an infection control issue and the urinal can transmit diseases
from the trash to the resident.
During a review of the Policy and Procedure (P&P) named Policy: Infection Control, last reviewed on
7/16/2024, the P&P indicated the facility will maintain an infection control program designed to provide a
safe, sanitary and comfortable environment and help prevent the development and transmission of disease
and infection.
During a review of the P&P named Bedpan/Urinal, Offering/Removing, last reviewed on 7/16/2024, the P&P
stated to store the urinal clean, dry and per facility policy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 79 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Level of Harm - Minimal harm
or potential for actual harm
5. During a review of Resident 182's admission Record, the admission Record indicated the facility
originally admitted the resident on 3/29/2025 and readmitted the resident on 4/29/2025 with diagnoses
including but not limited to cerebral infarction (an obstruction of blood flow in the brain that leads to tissue
damage) and acute respiratory failure (a condition where the lungs cannot release enough oxygen into the
blood).
Residents Affected - Some
During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025,
the MDS indicated Resident 182 had severely impaired cognitive skills (problems with the ability to think,
learn, and remember clearly) for daily decision making and required total assistance from staff with
activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 182's Physicians Orders, the Physicians Orders indicated an order for padded
siderails to decrease potential injury dated 4/30/2025.
During a review of Resident 642's admission Record, the admission Record indicated the facility admitted
the resident on 5/1/2025 with diagnoses including but not limited to acute respiratory failure and
intracerebral hemorrhage (bleeding inside the brain tissue).
During a review of Resident 642's History and Physical, dated 5/3/2025, the History and Physical indicated
Resident 642 was not alert or oriented (a person's awareness of their surroundings, including who they are,
where they are, and what time it is) and was unable to move any extremities.
During a review of Resident 642's Physicians Orders, the Physicians Orders indicated an order for padded
siderails to decrease potential injury dated 5/5/2025.
During a review of Resident 643's admission Record, the admission Record indicated the facility admitted
the resident on 4/10/2025 diagnoses including but not limited to cerebral infarction and acute respiratory
failure.
During a review of Resident 643's MDS, dated [DATE], the MDS indicated Resident 643 had severely
impaired cognitive skills for daily decision making and required total assistance from staff with ADLs.
During a review of Resident 643's Physicians Orders, the Physicians Orders indicated an order for padded
siderails to decrease potential injury dated 4/12/2025.
During a concurrent observation and interview on 5/7/2025 at 9:24 a.m. with Environmental Services
Worker 1 (ESW 1) and the Infection Preventionist (IPN) in room [ROOM NUMBER], ESW 1 wiped down the
hard plastic bed rails but not the black foam bed rail padding covering the bed rail. ESW 1 stated she does
not wipe them down because of the type of soft surface they are made of they get too wet when using
cleaning products. The IPN stated it is possible for the foam padding to harbor bacteria. The IPN stated they
replace the foam padding but she was not sure how often they replace it. The IPN was unable to provide a
policy and procedure on cleaning or replacing the foam bed rail padding when requested.
During a concurrent interview and record review on 5/7/2025 at 10:13 a.m. with the Maintenance Director
(MD), the MD stated the foam should be cleaned with the hydrogen peroxide wipes in the green packaging.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 80 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a concurrent interview and record review on 5/8/2025 at 2:39 p.m. with the Director of Nursing
(DON), photographs of Resident 182, 642, and 643's padded bed rails were reviewed. The DON stated the
ripped and gouged bed rail padding was not in good repair and could potentially harbor bacteria.
During a review of the manufacturers instructions for Clorox Healthcare Hydrogen Peroxide Cleaner
Disinfectant Wipes, dated 2024, the manufacturers instructions indicated the product cleans, disinfects, and
deodorizes hard, nonporous medical surfaces.
During a review of the facility's policy and procedure (P&P) titled Homelike Environment, last reviewed
7/16/2024, the P&P indicated residents are to be provided with a safe, clean, comfortable, environment.
During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, last
reviewed 7/16/2024, the P&P indicated surfaces will be disinfected with a disinfectant registered with the
Environmental Protection Agency according to the label's safety precautions and use directions. The P&P
further indicates manufacturers instructions will be followed including material compatibility.
6. During a concurrent observation and interview on 5/8/2025 at 8:05 a.m. with Respiratory Therapist 1 (RT
1) in the storage room next to room [ROOM NUMBER], boxes containing medical supplies were on the
floor, the floor had visible dirt, and two personal backpacks and one personal sweatshirt were on top of
boxes containing medical supplies. RT 1 stated respiratory therapy supplies used for residents were stored
in this storage room. RT 1 stated personal belongings were stored in the storage room as there was not a
lot of space to store personal items elsewhere.
During a concurrent observation and interview on 5/8/2025 at 10:20 a.m. with Environmental Services
Worker 2 (ESW 2), ESW 2 cleaned debris off the storage room floor and scrubbed a stain off with a mop.
ESW 2 stated he was unsure when the floor of the storage room was last cleaned, and he does not usually
clean storage room floors.
During an interview on 5/8/2025 at 1:50 p.m. with IPN, IPN stated she would not say it was okay that the
boxes were stored directly on the floor, but that they have been stored that way for a long time and there
has never been an issue. The IPN stated the floor of the storage room should be clean to maintain the
equipment.
During an interview on 5/8/2025 at 2:39 p.m. with DON, the DON stated the floor of the storage room
should be clean to prevent contamination. The DON stated storing boxes with medical supplies on the floor
and keeping employee personal items on top of the boxes could lead to contamination or possibly spread
an infection to a resident.
During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, last
reviewed 7/16/2024, the P&P indicated floors will be cleaned on a regular basis, when spills occur, and
when visibly soiled.
During a review of the facility's P&P titled, Storage Areas, Maintenance, last reviewed 7/16/2024, the P&P
indicated storage areas shall be maintained in a clean and safe manner.
During a review of the facility's P&P titled, Receipt and Storage of Supplies and Equipment last
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 81 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0880
reviewed 7/16/2024, the P&P indicated all supplies and equipment must be stored in accordance with the
manufacturer's recommendations.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 82 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0907
Provide enough space and equipment to meet each resident's needs
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the therapy gym had adequate space
and equipment to provide therapy services by failing to ensure:
Residents Affected - Some
1. One of two therapy mats functioned properly and was accessible for resident care.
2. One of eight hand weights was well-maintained for residents' use.
3. One of one oxygen concentrators (medical device used for delivering oxygen) was serviced.
4. One of one containers of ultrasound (imaging test that uses high-energy sound waves to look at tissues
and organs inside the body) gel was not expired.
These failures had the potential to place residents receiving therapy services from safe and optimal use of
the therapy equipment.
Findings:
During an observation on [DATE] at 9:43 a.m., in the therapy gym, one combination ultrasound and
electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or
manipulate nerves to reduce pain) machine was in the therapy gym.
During a concurrent observation and interview on [DATE] at 9:48 a.m., with the Director of Rehabilitation
(DOR), the DOR provided the ultrasound gel container which indicated an expiration date of [DATE]. The
DOR stated the ultrasound gel was used with the ultrasound machine to address chronic pain and soften
soft tissue (non-bony tissues in the body including muscles, tendons, ligaments). The DOR stated the
ultrasound gel had been expired for one-and-a-half years and would limit the effectiveness of the ultrasound
to address a resident's pain and soft tissue concerns.
During an observation on [DATE] at 9:52 a.m., observed one therapy mat was located toward the entrance
of the therapy gym.
During a concurrent observation and interview on [DATE] at 10:00 a.m., with the DOR, observed a second
therapy mat (therapy mat #2) was located toward the back of the therapy gym. The therapy mat was
unplugged and had therapy equipment scattered over the surface of the therapy mat, including a bean bag
toss game, eight hand weights, two arm bicycles, a therapy rainbow arch (plastic tubing in a rainbow
shaped used to work on arm range of motion [(ROM)] full movement potential of a joint]). One of the eight
hand weights was an eight (8) pound (lbs.- unit of measurement) hand weight with its smooth, protective
coating chipped off, exposing the metal. The DOR stated therapy mat #2 was broken and was used as
equipment storage for the therapists' convenience. The DOR stated the arm bicycles were broken and were
supposed to be thrown out. The DOR stated the 8 lbs. hand weight was used as a paperweight and not for
resident care. The DOR stated therapy mats (in general) were used to practice bed mobility (ability to move
within the confines of a bed, including activities like rolling, scooting, and transitioning between lying, sitting,
and standing positions), perform exercises, and work on balance activities with residents. The DOR stated
therapy mat #2 was used as storage and not usable for resident care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 83 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0907
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a concurrent observation and interview on [DATE] at 10:09 a.m., with the DOR, observed one
oxygen concentrator under a wooden table next to the second therapy mat. The DOR stated the oxygen
concentrator did not indicate the date it was last serviced. The DOR stated some residents residing in the
facility's subacute area (medical care setting where residents require more complex, round-the-clock care)
received therapy in the therapy gym. The DOR stated the oxygen concentrator could ineffectively deliver
oxygen since the last service date was unknown.
During a review of the facility's undated Policy and Procedure (P&P) titled, Rehabilitation Services, the P&P
indicated the therapy gym shall be equipped with necessary equipment, including a treatment table and
weights. The P&P also indicated Equipment shall be safe and adequate for resident needs and level of
services to be provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 84 of 85
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
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the
food services department when one (1) fly (a type of insect) was observed in the kitchen.
Residents Affected - Few
This failure had the potential to result in 138 of 199 residents, who received food from the kitchen, to
acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by
consuming potentially contaminated food.
Findings:
During an observation on 5/6/2025 at 11:06 a.m. one (1) fly was flying around the preparation area and
landed on the dessert rack.
During an observation on 5/6/2025 at 11:13 a.m. one fly was flying around the trayline area (an area where
foods were assembled from the steamtable to resident's plate).
During an interview on 5/6/2025 at 12:52 p.m. with the Dietary Supervisor (DS), the DS stated the pest
control vendor came in the beginning of 4/2025. The DS stated a fly landing on the food rack is not okay as
it could transmit diseases through food contact of the residents.
During a review of facility's policies and procedures (P&P) titled Pest Control Policy, reviewed 7/16/2024,
the P&P indicated, Policy: The facility shall maintain an effective pest control program. Policy Interpretation
and Implementation: (1) This facility maintains an on-going pest control program to ensure that the building
is kept free from insects and rodents.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 6.501.111 Controlling
Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to
eliminate their presence on the premises by:
a. Routinely inspecting incoming shipments of food and supplies.
b. Routinely inspecting the premises for evidence of pests.
c. Using methods, if pests are found, such as trapping devices or other means of pest control specified
under §§ 7-202.12, 7-206.12, and 7-206.13.
d. Eliminating harborage conditions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 85 of 85
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
31 citations 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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F907 - Space and Equipment
Provide enough space and equipment to meet each resident's needs
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the May 8, 2025 survey of CALIFORNIA HEALTHCARE AND REHABILITATION CENTER?
This was a inspection survey of CALIFORNIA HEALTHCARE AND REHABILITATION CENTER on May 8, 2025. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CALIFORNIA HEALTHCARE AND REHABILITATION CENTER on May 8, 2025?
Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.