Encino Hospital Medical Center D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. A plastic scoop was left in a food bin, in the dry storage area, during the initial kitchen tour. b. The facility failed to ensure food was labeled with a date, stored correctly and disposed of upon expiration. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in three of three medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter (a thin flexible tube that is inserted into the bladder to help drain urine) collection bag tubing was not looped or coiled to allow the urine to flow freely into the collection bag for two of two residents (Resident 1 and Resident 12) reviewed under the urinary catheter care area. This failure had the potential to result in the backflow of urine into the residents' bladders, which can cause urinary tract infections (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered through a tube in the stomach) by failing to indicate with a label, the date and time the enteral feeding tubing was started for one of one sampled resident (Resident 18) investigated under the tube feeding care area. This deficient practice had the potential for administering expired enteral feeding which could place Resident 18 at risk for complications such as diarrhea (loose, watery stool) or vomiting leading to dehydration (loss or removal of water).

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's kitchen ice machine Daily Scoop Sanitizer log was completed daily to indicate the ice scooper was sanitized daily. This failure had the potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of harmful bacteria that could contaminate the ice and cause foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins) in three of three medically compromised and vulnerable residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged incident of physical abuse involving one of one sampled resident (Resident 1) to the long-term care ombudsman (a person who investigates, reports on, and helps settle complaints) office, the local law enforcement agency, and the Department of Health Services in accordance with State law and the facility ' s policy and procedures, within but not later than two hours of the alleged involved incident. This deficient practice resulted in the California Department of Public Health (CDPH) being unaware of this alleged abuse incident and potential injury to Resident 1, which could then had the potential for a delay in CDPH ' s investigation and other abuse allegations to go unreported at the same facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely and thorough investigation for one of one sampled residents (Resident 1) when a Certified Nurse Assistant 1 (CNA) allegedly pulled Resident 1 ' s wheelchair from Resident 1 therefore causing Resident 1 ' s to suffer a fall from the wheelchair on 10/14/2024 at 9:00 p.m. On 10/15/2024, Resident 1 was noted to have a purple bruise on her left buttock and Resident 1 reported body pain 3/10. This deficient practice had the potential to result in unidentified abuse affecting Resident 1 and therefore, the facility failure to conduct a thoroughly investigation of the alleged violation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Certified Nursing Assistant 2 (CNA 2) was not standing over a resident while feeding the resident for one (Resident 9) out of two sampled residents investigated for the care area of dignity. This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem. 2. Based on interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident`s room for one of one resident (Resident 19) investigated under Resident Rights. This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prohibition policy by failing to report immediately, but no later than two hours after the allegation was made, an allegation of staff to resident abuse (the willful infliction of injury with resulting physical harm, pain, or mental anguish) to the State Survey Agency (California Department of Public Health), ombudsman, and local law enforcement for one of three sampled residents (Resident 8). This deficient practice had the potential to result in a delay of an onsite investigation of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) did not transfer a resident from the wheelchair to the bed using a mechanical lift (a device used to assist with transfers and movement) without assistance from another staff for one of one sampled resident investigated under the accident care area (Resident 14). This deficient practice had the potential for the resident to sustain a serious injury in the event of a fall incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to ensure: 1. Food stored in the resident unit refrigerator was labeled with the resident`s name, room number, date of preparation and discarded after two days. 2. The refrigerator in the resident's unit has a thermometer. These deficient practices had placed two of two residents (Resident 9 and 21) at risk for foodborne illnesses (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) with common symptoms such as nausea, vomiting, stomach cramps, and diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene (the practice of cleaning your hands to prevent the spread of disease and infection) after doffing (to take off) her gown, touching a soiled linen cart, and leaving a resident's room for one (Resident 9) out of six sampled residents investigated under the care area of infection control. This deficient practice had the potential to place residents at increased risk of contracting an infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff protect and maintain residents privacy and confidentiality for one of two sampled residents (Resident 2) when a Charge Nurse (CN) 2 released Resident 2's medical information to Resident 1's family member (FM 1). This deficient practice resulted in Resident 2's medical information released to other people who do not have the rights to know about.

Inspectors wroteBased on interview and record review, the facility failed to support one resident's (Resident 1) right to access personal and medical records (all records maintained for the purposes of patient treatment, including reports, notes, orders, diagnoses, treatments, test results, photographs, medical images, and more); failed to provide Resident 1's and/or Resident 1's representative (RR, an individual who is authorized either by a patient or a State law, to make health care treatment decisions for the patient when the patient is unable to do so) access to the personal and medical records within 24 hours of a written request; failed to follow up and mail to the requestor (Resident 1's representative) a written statement explaining the delay and setting forth the date by which the facility will provide records or a response. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to make information available on how to file a grievance (an official statement of a complaint over something believed to be wrong or unfair) for one resident (Resident 1) and/or resident's representative (s) (RR). This failure resulted in violation of Resident 1's and/or Resident 1's representative to receive information on how to file a complaint in accordance with the Patient Rights and Responsibilities and the facility's policy and procedure.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' rights were honored when the facility limited Resident 1's legal representative's visitation to one hour a day. This failure had violated Resident 1's visitation rights by not honoring exercising the resident's rights to designate visitors of his/her choosing.

Inspectors wrote3. A review of Resident 1's Admission/Registration Record, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 1's Minimum Data Set (MDS- as assessment and care screening tool) dated 12/8/2024, indicated the facility admitted the resident on 7/13/2000. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident was dependent on staff for dressing, eating, toilet use, and personal hygiene. [...]

Inspectors wrote3. A review of Resident 18's Admission/Registration form, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure. A review of Resident 18's MDS dated [DATE], indicated the facility admitted the resident on 8/21/2018. The MDS indicated the resident sometimes had the ability to understand others and was rarely/never understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, toilet use, and personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' right to a dignified existence by failing to: 1. Ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of two sampled residents (Resident 3) investigated under the Dignity care area. This deficient practice had the potential to affect Resident 3's dignity and privacy. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) knocked on a resident's door before entering the room for one of two sampled residents (Resident 25) investigated for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to promote the resident's right to be informed of and participate in their treatment for one of two sampled residents (Resident 5) by failing to obtain consent and inform the resident or responsible party in advance of the risks and benefits of the psychoactive (affecting the mind or behavior) medication sertraline (used to treat certain mental/mood disorders such as depression [(mood disorder that causes a persistent feeling of sadness and loss of interest]). This deficient practice violated Resident 5's and/or their responsible party's right to make an informed decision regarding the use of a psychoactive medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide professional standards of care to residents receiving care for deep vein thrombosis (DVT, a blood clot [gel-like clump of blood] that develops in one of the large veins in the body) prophylaxis (prevention) for one of six sampled residents (Resident 7) investigated for Position/Mobility by failing to clarify the physician's order for sequential compression device (SCDs, a machine that intermittently pumps air into sleeves wrapped around the lower legs in order to increase blood flow and prevent DVTs) and apply the SCDs. This deficient practice had the potential to result in a DVT for Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological [related to the mental and emotional state of a person] dependence) for two of 37 shift opportunities investigated during the Medication Storage task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure frozen poultry was dated while thawing in the refrigerator. This deficient practice had the potential to place two out of 27 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal vaccines (medications used to prevent lung infections caused by streptococcus pneumoniae [a type of bacteria]) was offered and residents and/or their representatives were educated about the risk and benefits of the vaccines for two of five sampled residents (Resident 3 and 7). This deficient practice placed Resident 3 and 7 at a higher risk of acquiring and developing complications from pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to protect and promote the interest and safety for one of one sampled resident (Resident 1). This failure resulted in a violation of Resident 1's rights and had the potential to negatively affect Resident 1's health outcomes and wellbeing.