Tarzana Health And Rehabilitation Center

During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired, and the resident had impaired ROM in one upper extremity (shoulder, elbow, wrist, hand) and both lower extremities (hip, knee, ankle, foot).

The MDS further indicated that Resident 3 was dependent on staff for Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) except for eating, which required moderate assistance.

The MDS also indicated that transfers were not attempted and that the resident used a wheelchair for mobility (movement).

During a review of Resident 3's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated the following: The gait/balance section was marked as balance problems while standing and walking.The SBP section was marked: No noted drop between lying and standing.

During a review of Resident 3's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated the following: The vision status section was left blank.The gait/balance section was marked as balance problems while standing and walking.The SBP section was marked: No noted drop between lying and standing.

During a concurrent interview and record review on 5/27/2026 at 1:33 p.m., with MDSN 1, MDSN 1 reviewed Resident 3's Fall Risk Assessments dated 3/26/2026 and 4/10/2026. MDSN 1 stated that Resident 3 was dependent on staff for all ADLs and was unable to stand; therefore, SBP could not be assessed between lying and standing positions.

However, the assessment was marked as no noted drop between lying and standing. MDSN 1 further stated that the resident used a wheelchair and that the vision status section on the 4/10/2026 Fall Risk Assessment was left blank. MDSN 1 stated the Fall Risk Assessments were completed incorrectly and incompletely and should be performed accurately to identify resident-specific fall risk factors and develop care plans to reduce the risk of falls.

During a review of the facility's policy and procedures (P&P) titled, Fall Prevention Program last reviewed on 4/30/2026, the P&P indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

The facility utilizes a standardized risk assessment for determining a resident's fall risk.

056124 05/28/2026

Tarzana Health and Rehabilitation Center 5650 Reseda Blvd Tarzana, CA 91356

During a review of LVN 4's personnel file including the Reference Check Control Form dated 5/11/2025, the Reference Check Control Form indicated that the facility contacted the applicant's wife and two co-workers as references. LVN 4's date of hire was 5/12/2026.

During a concurrent interview and record review on 5/27/2026 at 4:05 p.m., with the ADM and the DON, the ADM and the DON reviewed LVN 4's personnel file, including the Reference Check Control Form dated 5/11/2026.

The DON stated that the facility had contacted the applicant's wife and two former co-workers; however, the form did not indicate their job titles or positions.

The DON stated that the facility should attempt to verify an applicant's work experience, including any history of resident abuse, through appropriate employment reference and should document the name and title of the individual contacted. 2. c.

During a review of DSD's personnel file including the Confidential Reference Checks One, Two, and Three signed on 10/30/2020, the Reference Check indicated that the facility contacted the applicant's friends and a co-worker as references.

The DSD's date of hire was 11/3/2020.

During a concurrent interview and record review on 5/27/2026 at 4:09 p.m., with the ADM and the DON, the ADM and the DON reviewed the DSD's personnel file, including the Confidential Reference Checks One, Two, and Three, signed on 10/30/2020.

The ADM stated that a criminal background check was completed prior to hire and did not indicate any history of criminal offenses.

The ADM further stated that friends or co-workers could provide the information regarding whether a potential employee had a history of resident abuse; therefore, the facility did not need to contact the former employers.

The ADM stated that the criminal background check, with no adverse findings, was sufficient after reviewing the screening requirements in the facility's Abuse, Neglect, and Exploitation P&P.

During a concurrent interview and record review on 5/28/2026 at 12:40 p.m., with the ADM, the ADM stated that the facility did not have a P&P addressing employment reference checks during the new employee hiring process.

The ADM further stated that the issue would be discussed with the facility's consultants and that the ADM was uncertain whether such a policy was required.

The ADM reviewed the ADM's job description and stated that one of the ADM's duties and responsibilities under administrative functions was to plan, develop, organize, implement, evaluate, and direct the facility's programs.

During a review of the facility's P&P titled, Governing Body last reviewed on 4/30/2026, the P&P indicated, The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility.The governing body refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility.

During a review of the facility's Job Description for Administrator dated 2017, the Job Description for Administrator indicated, The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.

Administrative functions.

Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board.