Casitas Care Center
CASITAS CARE CENTER in GRANADA HILLS, CA — inspection on March 26, 2026.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted the resident on 3/31/2020ˆwith diagnosis including,ˆmajor depressive disorder (a serious mental health condition characterized by persistent, severe sadness, loss of interest, and low energy lasting at least two weeks) and hypertension (high blood pressure).
During a review of Resident 26's Minimum Data Set (MDS-a standardized assessment and care screening tool) datedˆ3/02/2026, the MDS indicated Resident 26 had the ability to understand others and be understood and requiredˆsupervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, showers, lower body dressing and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral hygiene, upper body dressing, putting on and taking off footwear and personal hygiene.
During a concurrent observation and interview on 3/28/2026 at 12:15 p.m. with Certified Nurse Assistant 1 (CNA 1) outside of the main dining room, CNA1 was observed receiving a finished meal tray, from a staff member, containing a cup of ice cream and a crumpled plastic shrink wrap. CNA1 disposed of these items in the trash bin without wearing gloves and did not sanitize her hands after completing the task. CNA 1 then proceeded to wheel an open meal cart with three new meal trays and a container of food containing an unidentified soup. As CNA 1 was wheeling the meal cart, staff were observed taking out the trays from the meal cart.
When CNA 1 reached the room of Resident 26, she then took out the container of food with an unidentified soup with her bare hands and entered the resident`s room without knocking and delivered the food container and placed them in the overbed table and removed the lid.
When interviewed, CNA 1 stated that she should have performed hand hygiene by washing her hands or use a hand sanitizer after discarding items from a dirty tray and before delivering the food to Resident 26. CNA 1 stated that hand hygiene (washing, sanitizing) is important before touching meal trays to prevent infection and cross contamination among residents and staff. CNA 1 stated that she should have knocked on the resident`s door and asked permission to go in as a sign of respect for their right to privacy.
During a review of the facility`s policy and procedure titled Dignity, last reviewed on 1/05/2026, the policy indicated that Each resident shall be cared forˆin a manner that promotes and enhances his or her sense of well- being, levelˆof satisfaction with life, and feeling of self-worth and self-esteem.staff are expected to knock and request permission before enteringˆresidents` rooms.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a concurrent observation and interview on 3/25/2026 at 10:56 a.m.ˆwith the Maintenance Supervisor (MS) at Resident 91's bedside,ˆtheˆMSˆobservedˆand validatedˆthe dust build up on the resident'sˆfan and cord covering along the wall.ˆTheˆMSˆstatedˆthe facility provided this fan for the resident and it came from theˆfacility'sˆstorage.ˆTheˆMSˆstatedˆthere should not be dust in the observed areas and they should have been cleaned.ˆTheˆMSˆstatedˆhe was the supervisor for both the maintenance and housekeeping departments.ˆTheˆMSˆstatedˆhousekeeping should be cleaning these areas as a part of their regular duties.ˆTheˆMSˆstatedˆthey shouldˆbe dusted so they provide a clean area for the resident.ˆTheˆMSˆstatedˆthe dust could affect the air quality in the resident's room.ˆ ˆ During aˆreview of the facility's P&Pˆtitled, Homelike Environment,ˆlast reviewedˆ1/5/2026, the P&Pˆindicatedˆresidents are provided with a safe, clean,ˆcomfortableˆand homelike environment.
The P&P furtherˆindicatedˆthe facilityˆstaffˆand management maximizes, to theˆextent possible,ˆthe characteristics of the facility that reflect aˆpersonalized, homelike setting including a clean, sanitary, and orderly environment.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review of the facility's P&P titled Antipsychotic Medication Use, last reviewed 1/5/2026, the P&P indicated: An antipsychotic medication should be used only for conditions/diagnoses as documented in the record and as meets the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV TR) or subsequent editions. In addition, before initiating or increasing an antipsychotic medication for enduring conditions, the target behavior must be clearly and specifically identified and monitored objectively and qualitatively.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review ofˆResident 44's MDS dated [DATE],ˆthe MDS indicated the residentˆhad severely impaired cognitive (relating to or involving the processes of thinking and reasoning)ˆskills for daily decision making and never or rarely made decisions.
The MDS indicatedˆResident 44ˆwas dependent (helper doesˆall ofˆthe effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).ˆ ˆ During a concurrent interviewˆand record reviewˆon 3/26/2026 at 10:15ˆa.m.ˆwith theˆInfection Preventionist, Resident 44'sˆImmunization Reportˆand care planˆwere reviewed. Resident 44's Immunization Reportˆindicatedˆthe resident had not received the updated 2025/2026 COVID-19 or influenza vaccinations.ˆThe IP stated Resident 44ˆwas not capable of makingˆher own decisions, and her representative had refused the vaccines.ˆResident 44's care plan did notˆindicateˆthe resident had not received these vaccinations or any interventionsˆregardingˆthe representative'sˆrefusal.ˆThe IPˆstatedˆa care plan should be madeˆregardingˆtheseˆrefusals,ˆso nursing staff knows toˆmonitorˆthe resident for in case they develop anyˆsymptoms of the flu or COVID, to reeducate the resident's representative, and to preventˆillness.ˆ ˆ During aˆreview of the facility's policy and procedureˆ(P&P)ˆtitled, Care Plans, Comprehensive Person-Centered,ˆlast reviewedˆ1/5/2026, the P&Pˆindicated a comprehensive person-centered care plan that includes measurable objectives and timetablesˆto meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.ˆThe P&P furtherˆindicatedˆassessments ofˆtheˆresident are ongoing and care plans are revised as information about the resident and resident's condition changes.ˆ
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review of Resident 54's physician's order, dated 1/25/2025, the physician's order indicated a PRM set at level three should be used for skin integrity management.
During a review of Resident 54's Braden Scale (an assessment tool used to predict a resident's risk of developing pressure related damage to the skin and/or underlying tissue usually over a bony prominence) dated 2/4/2026, the Braden Scale indicated Resident 54 is at high risk of having pressure related skin damage.
During a review of Resident 54's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 2/5/2026, the MDS indicated Resident 54 has severely impaired cognitive skills for daily decision making. Resident 54 requires a helper to do all the effort for activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During an interview on 3/26/2026 at 10:15 am with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the facility started using a new pressure redistribution mattress (PRM).
These mattresses are used for those with pressure ulcers as well as those that are bed bound (unable to leave one's bed).
During a concurrent observation and interview on 3/26/2026 at 11:15 am with the Director of Nursing (DON), the PRM was turned off.
The DON stated the power was off on the PRM.
When the power is off on the PRM, it cannot control the air flow at level 3 as ordered.
The DON further stated the PRM being turned off places Resident 54 at risk of developing pressure related skin damage and skin that will not be maintained.
During a review of the facility's PRM user-service manual dated 2022, the service manual indicated loss of power requires pump hoses to be disconnected from the mattress to continue air redistribution in the mattress.
During a review of the facility's policy and procedure (P&P) titled Support Surface Guidelines, revised 2013, the P&P indicated any individual at risk for developing pressure ulcers should be placed on a redistribution support surface.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
is conducted by two licensed nurses and is documented on the controlled medication accountability
drugs, antibiotics, CSs,.is supplied by the provider pharmacy in limited quantities in portable, sealed
sealed kits are replaced with the new sealed kits within 72 hours of opening.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review of
policy and procedures (P&P), titled Administering Medications, last reviewed 1/5/2026, the P&P
are administered in accordance with prescriber orders, including any required time frame. 7.
The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
During a review of the facility's P&P titled Medication Administration - General Guidelines, last reviewed 1/5/2026, the P&P indicated Medications are administered as prescribed. 2.
Medications are administered in accordance with written orders of the attending physician.
During a review of the facility's P&P titled Procedures for All Medications, last reviewed 1/5/2026, the P&P indicated: To administer medications in a safe and effective manner. F.
Read medication label before administering.
During a review of the facility's P&P titled Adverse consequences and Medication Errors, last reviewed 1/5/2026, the P&P indicated: 2. An ?adverse consequence' is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a.
Adverse drug/medication reaction; b.
Side effect; 4.
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; 3. 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. 4.
Examples of medications errors include: e. wrong dosage form.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
Based on observation, interview, and record review the facility failed to store medications in
procedures by failing to ensure eye drops were stored separately from orally administered medications, in one (1) of three (3) inspected Medication Carts (Medication Cart 1 Station 1.) ˆ This deficient practice increased the risk of contamination of medications and receiving medications via the wrong route (internal versus external routes,) for residents in the facility, possibly leading to adverse health consequences resulting in the negative impact to their health and well-being.
Findings: During a concurrent observation and interview on 3/23/2026 at 1:08 p.m., in Medication Cart 1 Station 1, with Licensed Vocational Nurse 3 (LVN 3), the following medications were stored in a manner contrary to the facility's P&P: -One (1) artificial tears (a medication used for dry eyes) eye drop bottle and one (1) atropine (a medication used to dilate the pupils of the eye)ˆeye drop bottle was stored with several oral medication bottles (including docusate [stool softener], acetaminophen [pain medication], vitamin b complex [supplement], lactobacillus [probiotic], oyster shell calcium [supplement], glucosamine [joint support] in the same bin/container of the medication cart. LVN 3 stated that eye drops should be stored separately from oral medications, to prevent errors in wrong route administration and possible infections/contaminations. LVN 3 acknowledged one (1) medication bin/container contained one (1) artificial tear eye drop bottle and one (1) atropine eye drop bottle with several orally administered medication bottles. LVN 3 stated the facility failed to store eye drops separate from oral medications.
During an interview, on 3/24/2026 at 3:15 p.m., with the Director of Nursing (DON,) the DON stated internally (such as oral) and externally (such as eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations.
The DON stated the facility failed to store the artificial tears and atropine eye drop bottles in Medication Cart 1 Station 1 separate from several orally administered medication bottles.
During a review of facility's P&P titled, Storage of Medications, last reviewed on 1/5/2026, the P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. C.
Orally administered medications are kept separate from externally used medications.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review of Resident 4's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 1/12/2026, the MDS indicated Resident 4 had severely impaired cognitive skills for daily decision making and required a helper to do more than half of the effort for toileting hygiene, showers and baths, dressing, sit to lying, and lying to sitting on the side of bed.
During a review of Resident 4's Order Summary Report (OSR) dated March 2026, the OSR indicated to monitor Resident 4's orthostatic blood pressure while lying and sitting daily and report a drop in blood pressure to the physician.
During a review of Resident 4's Medication Administration Record (MAR) dated March 2026, the MAR indicated the same blood pressure while Resident 4 was lying and sitting on eight different days.
During a concurrent interview and record review on 3/25/2026 at 2:45 pm with Licensed Vocational Nurse (LVN) 1, Resident 4's MAR dated March 2026 was reviewed.
The MAR indicated LVN 1 had the same blood pressure reading while Resident 4 was lying and sitting that morning. LVN 1 stated the lying and sitting blood pressure reading were different and the documented blood pressure was taken while Resident 4 was lying down. LVN 1 further stated the orthostatic blood pressure readings are always different between lying and sitting.
During a concurrent interview and record review on 3/26/2026 at 11:00 am with the Director of Nursing (DON), Resident 4's Weights and Vitals Summary for March 2026 were reviewed.
The Weights and Vitals Summary indicated, only a lying blood pressure was taken on the morning of 3/25/2026.
The DON stated orthostatic blood pressure for Resident 4 cannot be determined due to inaccurate documentation.
The DON further stated inaccurate documentation will not show if the orthostatic blood pressure was taken which can cause miscommunication with the interdisciplinary team.
During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record will be objective, complete, and accurate.
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review of Resident 26's Minimum Data Set (MDS-a standardized assessment and care screening tool) datedˆ3/02/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others.
The MDS indicated that Resident 26 requiredˆsupervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, shower, lower body dressing and setup or clean-up assistance ( helper sets up or cleans up; resident completes activity) with eating, oral hygiene, upper body dressing, putting on/taking off footwear and personal hygiene.
During a concurrent observation and interview on 3/28/2026 at 12:15 p.m. with Certified Nurse Assistant 1 (CNA 1) outside of the main dining room, observed CNA 1 receive a finished meal tray from another staff which contained a cup of ice cream and crumpled plastic shrink wrap. CNA 1 disposed these items into a trash bin. CNA 1 did not perform hand hygiene (washing hands or using hand sanitizer) after discarding the trash. CNA 1 then proceeded to an open meal cart with three new meal trays and a container of soup.
Upon reaching Resident 26's room, CNA 1 removed the soup container from the meal cart using bare hands, entered the room, placed the food on the overbed table, and removed the lid. CNA 1 was not observed performing hand hygiene before delivering the meal to Resident 26. CNA 1 stated that she should have performed hand hygiene, either by washing her hands or using a hand sanitizer after discarding items from a soiled tray and prior to delivering the food to Resident 26, to prevent infection and cross contamination among residents and staff.
During a review of the facility`s policy and procedure (PP) titled Handwashing/Hand Hygiene, last reviewed on 1/05/2026, the PP indicated that This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infection.all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.hand hygiene is indicated immediately after touching the resident`s environment. ˆ ˆ
056148 03/26/2026
Casitas Care Center 10626 Balboa Blvd.
Granada Hills, CA 91344
During a review of the facility`s policy and procedure (P&P) titled Pest Control, last reviewed on 1/5/2026, the P&P indicated that Maintenance services assist, when appropriate and necessary, in providing pest control services.