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Deficiency Records for Encino Hospital Medical Center D/p Snf
A list of the most recent deficiencies for Encino Hospital Medical Center D/p Snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Encino Hospital Medical Center D/p Snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-03-19 | 2024-03-21 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-19 | 2024-03-19 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-01-30 | 2024-03-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-07 | 2024-01-30 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-07 | 2024-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-07 | 2024-01-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-07 | 2024-01-30 | N |
| 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. | Health | 2024-01-07 | 2024-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-07 | 2024-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-07 | 2024-01-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-07 | 2024-01-30 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-08 | 2024-01-10 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-09-29 | 2023-10-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-27 | 2023-08-18 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-06 | 2023-02-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-06 | 2023-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-06 | 2023-02-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-06 | 2023-02-03 | N |
| 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. | Health | 2023-01-06 | 2023-02-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-06 | 2023-02-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-06 | 2023-02-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-06 | 2023-02-03 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-06 | 2023-02-03 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-06 | 2023-02-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-12 | 2023-01-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-07-06 | 2022-08-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-21 | 2019-11-22 | N |
| 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. | Health | 2019-11-21 | 2019-11-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-21 | 2019-11-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-21 | 2019-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-21 | 2019-11-21 | N |
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