El Encanto Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled Advance Directives (AD, a written instruction, recognized under State law relating to the provision of health care when the individual was incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]), for four of six sampled residents (Residents 13, 39, 58, and 63) when: a. Resident 13's AD Acknowledgement Form (ADAF, part of an advance directive, a legal document that allowed a person to specify their medical care wishes and who should make decisions for them if they could not) was not completed.b. Resident 58's ADAF was not completed.c. Resident 39's AD was not in Resident 39's chart.d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to an individual who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication board/device in a language that the resident understood for two of two sampled residents (Residents 5 and 41). These failures had the potential to affect Residents 5 and 41's communication with staff resulting in a delay in the provision of care, treatment and services to Residents 5 and 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Residents 39, 59 and 62) by failing to:a. Follow the Physician Order (PO) to apply bilateral (both sides) 1/2 side rails at head of bed (HOB) for Resident 39.b. Obtain a PO and an informed consent on the use of bedside rails before its application for Resident 59. c. Ensure Resident 62's informed consent for the use of bilateral one-half (1/2) side rails indicated the name of the person giving the consent and the name of the staff verifying the consent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage and sanitary food storage in one of one facility kitchen by failing to:a. Label a tray with fifteen (15) small, square paper packages (juice box) of cranberry juice and fourteen (14) juice boxes of apple juice inside the kitchen cooler fridge with delivery date and used by (the last date recommended for the product to be used)/best by (when a product will have the best flavor, texture, or quality) date or expiration date (final date set by a manufacturer after which a product should not be used or consumed).b. Discard one (1) big, open plastic container of cranberry juice with date beyond the used by/best by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought by Family/Visitors, by failing to label outside food for two of two sampled residents (Residents 7 and 58). These deficient practices had the potential to result in food-borne illnesses (food poisoning) for Residents 7 and 58 and could lead to serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of five sampled residents' (Resident 6) target behavior was monitored for the use of psychotropic medication (medication that alter chemical levels in the brain which impact mood and behavior) as indicated in the facility's policy and procedure (P&P) titled Behavior Management. This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could result in significant adverse (harmful) consequences to Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS, a resident assessment tool) reflected an accurate discharge status assessment for one of one sampled resident (Resident 57). This failure resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Resident 57 not to receive interventions to address Resident 57's specific care concerns.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plan (CP) to meet the resident's needs for one of one sampled resident (Resident 26) to address Resident 42's use of quetiapine fumarate (medication that helps calm a person's thoughts and mood). This failure had the potential to result in Resident 26 not receiving individualized care to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Peripheral Catheter Dressing Change, by failing to label the intravenous (IV- medicine or fluid that goes straight into a vein) dressing for one of one sampled resident (Resident 58). This deficient practice had the potential to increase the risk of infection for Resident 58 and could lead to serious medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication regimen review (MRR) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled residents (Resident 39) in accordance with facility's policy and procedure California Long Term Care Facility Pharmacy Services and Procedures Manual. This deficient practice had the potential for unnecessary and over medication for Resident 39 that could result in harm due to the missed opportunity for a Gradual Dose Reduction (GDR, slow, supervised tapering of psychotropic [psychiatric medicines that alter chemical levels in the brain which impact mood and behavior] to the lowest effective dose or complete discontinuation).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases for one of four sampled residents (Resident 59) by failing to initiate and implement Enhanced Barrier Precaution (EBP, a set of infection control practices that used personal protective equipment [PPE, clothing and equipment used to provide protection] to reduce the spread of multi-drug resistant organisms [MDRO, a bacteria that was resistant to antibiotics-mediations for bacterial infection]. These failures had the potential to expose Resident 59 and other residents in the facility to infection.

Inspectors wroteBased on interview, and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available bed in a semi-private room on [DATE] after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on [DATE] and transferred to Long-Term Acute Care Hospital (LTACH) 1 on [DATE], in accordance with SNF 1's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 10/2022. This deficient practice resulted in Resident 1 remaining in LTACH 1 on [DATE] following an inquiry from LTACH 1 for Resident 1 to be transferred back to SNF 1 and had the potential to cause Resident 1 distress from not being able to return to Resident 1's previous living arrangement.(cross reference F628)

Inspectors wroteBased on interview, and record review, the facility failed to ensure a complete transfer or discharge process for one of three sampled residents (Resident 1) when:1. A Notice of Transfer or Discharge (NTD) was not provided to Resident 1 and/or to Resident 1's representative (RP) when Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 1/3/2026.2. A copy of an NTD was not sent to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 1/3/2026. These deficiencies had the potential to violate Resident 1's right to not be inappropriately transferred or discharged and had the potential for the Ombudsman to not be able to advocate for Resident 1 from being inappropriately transferred or discharged .(cross reference F627)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach and were functioning properly for two of three sampled residents (Residents 30 and 18). This failure had the potential for Residents 30 and 18 not to receive necessary care or receive delayed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 6/10/25, 6/11/25, and 6/12/25 in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information could mislead the residents and visitors regarding facility staffing and could affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow food storage handling practices in accordance with its Policy and Procedure (P&P) by failing to: 1. Remove expired food items from the refrigerator. 2. Label food items with food item name, use by or expired date. 3. Maintain a functional convection steamer (an oven that is designed to steam cook large quantities of food over multiple shelves). These deficient practices had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages) for the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled resident's (Resident 39) discharge destination was coded correctly in Resident 39's Minimum Data Set (MDS, a resident assessment tool). Resident 39 was discharge home but the MDS was coded as Resident 39 being discharged short term to the general hospital. This deficient practice resulted in reporting that was not accurate to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 17) was provided adequate supervision during activities of daily living (ADL, activities such as bathing, dressing, and toileting a person performs daily) by using a two-person assist to prevent a fall occurrence. This failure resulted in a fall which had the potential to result in severe harm or injury to Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Foley catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder [hollow muscular organ that acts as a reservoir for urine]) was secured on the resident's thigh for one of two sampled residents (Resident 141). This failure had the potential to result in catheter-related complications like tissue trauma and a physical decline to Resident 141.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen [colorless, odorless gas]) tubing for one of one sampled resident (Resident 140). This failure had the potential for Resident 140 to result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order, and an informed consent was obtained before the installation of bilateral (both sides) one-fourth (1/4) siderails/bedrails (adjustable metal or plastic bars attached to the bed) for one of three sampled residents (Resident 1). This failure placed Resident 1 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaced around the bed) and injury from the use of siderails/bedrails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bilateral (both sides) side rails pads were free from damaged, wear and tear, for one of one sampled resident (Resident 3). This deficient practice had potential to place Resident 3 at risk for injury from the use of damaged side rail pads.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff did not give medications to one of three sampled residents (Resident 1) without a current physician's order as indicated in the facility's policy and procedure (P&P) titled, Medication Administration. This deficient practice had the potential to result in the unnecessary use of medication, medication errors, and adverse side effects for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Charting and Documentation, by failing to document a complete assessment (the process of evaluating a patient's condition) for one of three sampled residents ' condition (Resident 1). This deficient practice had the potential to not provide complete information regarding Resident 1 ' s condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's call light was within reach for two of two sampled residents (Residents 20 and 27). These deficient practices had the potential for Residents 20 and 27 not to receive necessary care or received delayed services to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Advance Directive/Preferred Intensity of Care Documentation form (AD, a written instruction, recognized under State law relating to the provision of health care when the individual becomes incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) was in the resident's medical record for two of two sampled residents (Resident 35 and 2). These failures had the potential for staff to provide care and services against the resident's will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a communication device in a language that the resident understood for two of three sampled residents (Residents 20 and 34). These deficient practices had the potential to affect Residents 20 and 34's communication with the staff and had the potential for the delay of the provision of care, treatment, and services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with the facility's Policy and Procedure (P&P) on dating open food containers, refrigerated food storage labeling and dating and hair net policy, for one of one facility kitchen, by failing to: A. Label one bottle of salad dressing, one carton of milk, one canister of chopped onion seasoning, one canister of garlic herb cayenne pepper, and one canister of chicken flavor base, with the open date. B. Discard one tray of nourishments that contained yogurt, prunes, and cottage cheese from the refrigerator dated 6/12/2024. C. Wear a beard net for two staff members who had facial hair while working in the facility's kitchen area on 6/19/2024. These failures had the potential to result in food contamination and food borne illnesses (illness from ingesting contaminated food).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its binding arbitration agreements included selection of a venue convenient to both facility and resident/resident responsible party for three of three sampled residents (Residents 16, 20 and 35). These deficient practices placed Residents 16, 20 and 35 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on interview and record review, the facility failed to ensure a quarterly Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) was timely completed within the required time frame for one of one sampled resident (Resident 4). This deficient practice had the potential to negatively affect the provision of necessary care for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a specific and individualized person-centered care plan to meet the resident's needs for one of one sampled resident (Resident 20) who was assessed with hearing difficulty. This deficient practice had the potential for Resident 20 not to receive the necessary care, treatment, and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date the Intravenous (IV- administered into a vein) site consistent with professional standards of practice for one of one sampled resident (Resident 93). This deficient practice had the potential to result in infection and worsen Resident 93's medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the its Policy and Procedure (P&P) on Enhanced Barrier Precaution (EBP, precautions that include the use of a gown and gloves during high contact resident care activities for residents) to prevent the spread of infections for one of five sampled residents (Resident 35) for infection control when Licensed Vocational Nurse 7 (LVN 7) did not don (put on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards ) before taking the blood pressure of Resident 35 in an EBP room. This failure had the potential to result in transmission of multidrug-resistant organisms (MDRO, bacteria that is resistant to antibiotics) to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post actual nurse staffing data at the beginning of each shift daily for two of two sampled locations (lobby and nursing station) on 6/18/2024 and 6/20/2024. These failures had the potential to result in not providing nurse staffing information to residents and visitors and had the potential to affect the quality of care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of two sampled residents (Resident 1) to the Ombudsman and local law enforcement. This deficient practice had the potential for delayed investigation of abuse for Resident 1.