Tarzana Health and Rehab: BP Medication Safety Failures - CA
The resident, identified in inspection records as Resident 1, was admitted to the facility on April 2, 2026, with diastolic congestive heart failure and high blood pressure. His physician ordered two medications, furosemide and losartan, both carrying the same written instruction: hold the dose if the resident's systolic blood pressure fell below 110 millimeters of mercury. The orders were explicit, documented, and dated from his first days at the facility.
They were not followed.
On April 9, nurses recorded his systolic pressure at 107 and gave him both medications anyway. Five days later, on April 14, his pressure had fallen further, to 98, and he received them again. The threshold for withholding the drugs was 110. On both days, his pressure was beneath it.
The facility's own MDS nurse, reviewing the medication administration records with inspectors during a concurrent interview on the afternoon of April 30, confirmed the violations without equivocation. She stated that before giving blood pressure medications, licensed nurses are supposed to take the resident's pressure, then check the physician's order for any parameters. She looked at the records and said directly that the medications should not have been given on either day.
She also described what could have happened. Administering furosemide and losartan to a patient whose systolic pressure had already dropped that low carries the risk of pushing his blood pressure lower still, which can cause lethargy, dizziness, and a transfer to the hospital.
Resident 1 was not a patient who could easily speak up for himself. An assessment completed April 8 documented that his cognitive skills for daily decision-making were moderately impaired. He needed staff assistance or supervision to eat, manage personal hygiene, and brush his teeth. He was dependent on staff for bathing and toileting. His ability to recognize or report that something had gone wrong with his medications was limited.
Furosemide is a diuretic, meaning it pulls fluid from the body, a common treatment for heart failure but one that also lowers blood pressure. Losartan works by relaxing blood vessels, which lowers pressure further. Given together to a patient whose systolic reading is already in the high 90s, the combination pushes in exactly the wrong direction. The doctor's hold parameters existed to prevent that.
The facility's own written medication policy, last reviewed in April 2025, states that nurses should obtain and record vital signs when applicable and hold medications when those signs fall outside the physician's prescribed parameters. The policy was current. The orders were clear. On April 9 and April 14, neither mattered.
Inspectors rated the violation as having the potential for actual harm, with few residents affected. The finding was cited under federal standards requiring facilities to ensure residents receive medications only as ordered, with pharmacist oversight of the medication program.
What the inspection record does not contain is any explanation for how the same error happened twice in five days, to the same resident, with the same two medications, under the same documented physician order. The MDS nurse offered no account of what the administering nurses were or were not checking before they gave the doses. There is no record in the inspection findings of any internal review, any staff retraining, or any notification to Resident 1's family that he had twice received medications his doctor had ordered withheld.
He came to Tarzana with a heart that already struggled to relax properly between beats. The medications meant to protect him were given to him on two days when his body was already under more pressure than his doctor believed was safe to medicate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tarzana Health and Rehabilitation Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
TARZANA HEALTH AND REHABILITATION CENTER in TARZANA, CA was cited for violations during a health inspection on April 30, 2026.
The orders were explicit, documented, and dated from his first days at the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.