Granada Hills Convalescent

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two of two sampled residents (Residents 6 and 19) reviewed for physical restraints care area by failing to ensure: 1. Resident 6's use of restraint bed placed against the wall had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and restraint assessment. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a personalized document that outlines a person's health needs, the goals for their care, and the specific steps to achieve them) for three of four sampled residents (Residents 43,19, and 3) reviewed for care plans by failing to ensure: 1. Resident 43 had a care plan for medication self-administration. 2. Resident 19 had care plan on the use of restraint (is any action, device, or medication that limits a resident's ability to move freely or control their own body, and which they cannot easily remove themselves) bed placed against the wall. 3. Resident 3 had a care plan for diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with a person-centered measurable goal. [...]

Inspectors wroteBased on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of practice for one of five residents (Resident 7) investigated for unnecessary medications by failing to follow the hold parameters for losartan (a medication used to treat high blood pressure), and midodrine (a medication is used to treat low blood pressure) as ordered by the physician. This deficient practice had the potential to cause complications such as dizziness, syncope (fainting) and possible hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of four sampled residents (Residents 43, 23, 39, and 6) reviewed for accidents by failing to ensure: 1. Residents 23, 39, and 6's fall mats (a cushioned mat that reduces the risk of injury from a fall) did not have a furniture or equipment on top of them. 2. Resident 43 did not have any medications left at the bedside. These deficient practices increase the risk of accidents such as injuries associated to resident slips, trips, and falls by hitting the hard surface of the equipment or furniture that is on top of the fall mat and accidental ingestion of harmful chemicals. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident 7) investigated for unnecessary medications by failing to follow the hold parameters for losartan (a medication used to treat high blood pressure), and midodrine (a medication is used to treat low blood pressure) as ordered by the physician. This deficient practice had the potential to cause complications such as dizziness, syncope (fainting) and possible hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when [NAME] (CK) 1 was unable to prepare pureed baked fresh zucchini and pureed garlic bread in a consistency that passed all the established testing guidelines including spoon-tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Standardization Initiative (IDDSI-a framework for categorizing food textures and drink thickness) level four (4). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree baked fresh zucchini and puree garlic bread was too watery and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Standardization Initiative (IDDSI-a framework for categorizing food textures and drink thickness) level four (4). This deficient practice had the potential to result in decreased food and nutrient intake to seven (7) of seven (7) residents on puree diet, resulting in aspiration (when something other than air gets into your airways) and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of one of one sampled resident (Resident 39) reviewed under accommodation. This deficient practice had the potential for Resident 39 unable to summon a health care worker for help as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning wall clock for one of nine sampled residents (Resident 10). This deficient practice has the potential to placed Resident 10 at risk for disorientation and compromised the facility's obligation to provide a homelike and supportive environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of nine sampled residents (Residents 6) who participated in the Resident Council meeting, was aware of the facility's grievance policy and procedures. This deficient practice placed the resident at risk for unresolved dissatisfaction and undermines the facility's obligation to maintain a transparent and responsive care environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received services and assistance to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of two sampled residents (Resident 39) reviewed for UTI by failing to ensure Residents 39's urinal bottle (portable container for collecting urine) was labeled with the name or room number of the residents. The deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another), development of UTI, and potential switching of urinal bottle with other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 39) reviewed for hydration by failing to: 1. Label the peripherally inserted central catheter (PICC, a long, thin tube inserted into a vein in the arm that travels up to a large vein near the heart) line with the date of last dressing change. 2. Change the loose and soiled PICC line dressing. 3. Obtain an order for PICC line dressing changes. The deficient practices had the potential for complications associated with intravenous therapy and catheter-related infections.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was provided treatment in accordance with standards of practice by failing to ensure that the dialysis center recorded a resident's pre and post dialysis weights (the weight before and after fluid is removed during the dialysis treatment) on 11/17/2025 for one of one sampled resident (Resident 7) receiving dialysis treatment. This deficient practice had the potential for Resident 7 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices when Resident 10 was observed removing clean linens from a covered clean unattended linen cart located in facility hallway. This deficient practice had the potential to contribute to contamination (making something dirty) of clean linens increasing the risk of infection transmission to residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, a government-mandated form given to a patient when the facility believes their Medicare coverage for skilled services is ending) two days before the termination of services for two of three sampled residents (Residents 9 and 17) reviewed for Beneficiary Notification. This deficient practice had the potential to result in responsible parties not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (a unit of measure) per resident in multiple resident bedrooms for 19 of 21 rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroted. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for two of six sampled residents (Residents 15, 44, 31, 6, and 12) investigated under accidents by failing to ensure 1. Resident 15, 44, 31, and 36's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of the mat. This deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the fall mat, decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and placed the residents at risk for injury if they were to hit the equipment or furniture during a fall. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Resident 15's nasal cannula oxygen tubing (a thin, flexible tube that delivers oxygen to a patient through two prongs that fit into the nostrils) was labeled with the date it was last changed for one of two sampled residents investigated under respiratory care. 2. Resident 32's nasal cannula oxygen tubing was off the floor and the nebulizer tubing (a tube that connects the compressor of a nebulizer to the medication cup) was labeled with the date it was last changed for one of two residents investigated under respiratory care. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the pad call light (a device with sensitive touch surface ideal for patients who may have difficulty using standard call cord to signal need for assistance from a professional staff) was within reach for one (1) out of 37 sampled residents. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay of care and services that can negatively affect resident's comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal [the body's system for processing liquids and foods] tract) received appropriate care and services to prevent complications of enteral feeding for one out of two sampled residents (Resident 27) by failing to ensure the enteral feeding tube tip attached to a Y adapter (a three-way connector in which two ends are adjacent to the tubing) was covered with a cap when not in use. The deficient practice had the potential to contaminate the enteral feeding system.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for one of two sampled residents (Resident 32) investigated under respiratory care by failing to ensure: 1. A physician's order was obtained for Resident 32's use of bilevel positive airway pressure (BIPAP, a noninvasive machine that helps people breathe). 2. The BIPAP mask and tubing were kept off the floor. These deficient practices had a potential for Resident 32 to develop respiratory complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services to one (1) of three (3) sampled residents (Resident 36) investigated during medication administration task. The facility failed to flush the medications in between administration via gastrostomy tube (G-tube - a medical device that is inserted through the abdomen into the stomach to provide nutrition, fluids, and medications to patients who are unable to consume food or liquids by mouth). This deficient practice had the potential to place Resident 36 at risk of health complications such as drug interaction and delay in the provision of care.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for one of two sampled residents (Resident 27) investigated under anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to ensure there was adequate monitoring on the use of an anticoagulant-Apixaban. The deficient practice had the potential to predispose the resident on the adverse effect (a harmful or abnormal result) of anticoagulant use such as bleeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard nine (9) boxes of BinaxNOW COVID-19 Antigen Self-Test ( a rapid antigen point-of-care test that can be used to diagnose an active COVID-19 [an infectious disease caused by the SARS-CoV-2 virus) used on staff and residents with expiration date of 1/18/2024 stored in the facility's Medication Room observed during medication storage and labeling facility task. The deficient practice increased the risk of the resident being misdiagnosed with COVID-19 that leads to delay in the care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the order for Restorative Nursing Assistance (RNA - a type of program in long term care facilities intended to restore lost abilities or maintain potentially deteriorating functions for residents) program was entered accurately in the electronic health record (EHR) for one (1) out of 1 sampled resident (Resident 36) during an investigation under the position/mobility care area. This deficient practice had the potential for incomplete and inaccurate medical documentation and cause a delay in provision of necessary care and services Resident 36 needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 19 of 21 resident rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 18, 19, 20, 21, 22, and 17) met the square footage requirement of 80 square feet (sq. ft., a unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of five sampled residents (Resident 1), by failing to ensure Registered Nurse 1 (RN 1) perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after providing care to Resident 1 and after touching unclean surfaces. RN 1 also did not wear gloves during the blood pressure monitoring procedure on Resident 1. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.

Inspectors wroteBased on interview, and record review, the facility failed to provide a safe environment to prevent an accident for one of three sampled residents (Resident 27) by transferring Resident 27 without two staff when using a lift machine. On 6/12/2023, at 6:20 p.m. Certified Nursing Assistant 1 (CNA 1) transferred by herself Resident 27 using a Hoyer lift (a brand name for a mobile floor lift system [assistant device] that rolls on wheels [metal frame] and is intended to help lift, suspend with a sling, and transfer residents with mobility problems to transfer from and to bed. During two-person operation, one person engages the unit's controls while the other person handles and guides the individual being transferred). [...]

Inspectors wroteBased on observation, interview and record review facility failed to maintain privacy of confidential information when Certified Nursing Assistant 3 (CNA 3) left an electronic health record (EHR- a digital version of a patient's paper chart) open , unattended, and out of view for one of one resident sampled (Resident 25). This deficient practice violated Resident 25's right to privacy and confidentiality of their medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement resident-centered care plans for two of 14 sampled residents (Resident 25 and Resident 87) by failing to: 1. Ensure Resident 25 had a care plan addressing the use of Cefdinir (an antibiotic [medicines that treat or prevent bacterial infections] medication). 2. Ensure Resident 87 had a care plan addressing the use of a cervical collar (C-collar, a medical device used to restrict movement whenever spinal motion restriction is indicated). These deficient practices placed the residents at risk for not receiving the necessary services and treatment to meet their medical, physical, mental and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality for a resident who has a gastrostomy tube (GT- a tube inserted through the abdomen and into the stomach used to deliver nutrition or medication)) by failing to verify the route of administration for a supplement, pro-stat (a ready-to-drink concentrated liquid protein medical food) prior to administration for one of one sample resident (Resident 27). This deficient practice had the potential to result in Resident 27 receiving the medication orally causing the resident to aspirate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure on labeling and storage of drugs and biologicals by: 1. Failing to label two Aplisol (a sterile aqueous solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]) multi-dose (multiple doses) vials with an open date for one of one medication storage reviewed. 2. Failing to label MiraLAX (a brand-name, over-the-counter product that is typically used to treat short-term constipation) with an open date during medication pass observation for one of one sampled resident (Resident 27). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices for one of one sampled resident (Resident 138), by failing to label Resident 138's oxygen tubing and humidifier with a placement (the action of putting something in a particular place) date. This deficient practice had the potential for staff to not timely change oxygen tubing and humifidier, placing the resident at risk for respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms meet the requirement of 80 square feet (a unit of measure) per resident in multiple resident bedrooms for 19 of 21 rooms (2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22). This had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.