Cycle 1
Health 2024-12-29 · Fire 2024-12-29
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Sun Valley, CA
Totally Kids Specialty Healthcare - Sun Valley
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
10716 La Tuna Canyon Road, Sun Valley, CA
(818) 252-5863
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.42
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
4.43
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
4.57
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
10.43
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
5.85
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
9.45
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
3.50
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 38% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 3.67% |
8.2%
4.5 pts worse
|
Numerator 8 · Denominator 218 |
| Staff flu vaccination coverage | 25.59% |
42%
16.4 pts worse
|
Numerator 65 · Denominator 254 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
98.5%
0.8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.2% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
4.1%
2.5 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.1% · Q3 5.4% · Q4 11.1% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.7% |
13.7%
34 pts worse
|
19.6%
28.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 46.2% · Q3 51.4% · Q4 50.0% · 4Q avg 47.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.2%
14.2 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.1% |
11.0%
3.9 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
10.7%
5.4 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.2%
1.4 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 0.0% · Q4 2.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.0% |
10.9%
10.9 pts better
|
19.8%
19.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
4.7%
4.1 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-18 · Fire 2023-12-18
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-12-23 · Fire 2021-12-23
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-23
F · Potential for more than minimal harm
2023-12-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-18
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-18
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-17
C · Minimal harm
2023-12-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-17
F · Potential for more than minimal harm
2021-12-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-21
F · Potential for more than minimal harm
2021-12-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-21
F · Potential for more than minimal harm
2021-12-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-29
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-29
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
F · Potential for more than minimal harm
2023-12-18
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-18
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-12
B · Minimal harm
2023-12-18
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-05-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-17
E · Potential for more than minimal harm
2021-12-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-01-17
E · Potential for more than minimal harm
2021-12-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-12-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-12-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-17
Penalties and ownership
What sits behind the stars
Ownership
Nydam, Michelle
5% Or Greater Direct Ownership Interest · Individual
Nydam, Robert
5% Or Greater Direct Ownership Interest · Individual
Nydam, Michelle
Corporate Director · Individual
Nydam, Michelle
Corporate Officer · Individual
Nydam, Michelle
W-2 Managing Employee · Individual
Nydam, Robert
Corporate Director · Individual
Nydam, Robert
Corporate Officer · Individual
Nydam, Robert
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Villa Scalabrini Special Care
Sun Valley, CA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Hills Healthcare Center
Sunland, CA
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Pacifica Hospital Of The Valley Dp SNF
Sun Valley, CA
1-star overall rating with 1-star inspections with $60,373 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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