Sherman Oaks Hospital SNF Dp

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to two (2) errors observed out of 26 total opportunities (error rate of 7.69 %) for two of six sampled residents (Resident 10 and Resident 2) observed during the Medication Administration Task by failing to:1)Ensure Registered Nurse (RN) 2 did not administer pantoprazole (Protonix - a proton pump inhibitor medication that reduces the amount of acid the stomach produces) to Resident 10, while the tube feeding was infusing during the 9 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual resident needs when residents receiving a pureed diet (foods that are soft, pudding like consistency and hold its shape), were served pureed smothered rice pilaf, herb baked cod, and carrots with a thin, watery consistency. The food items spread into one over the another appearing to merge on the plate rather than maintaining a cohesive, pudding like consistency. This failure had the potential to result in difficulty in swallowing, difficulty in eating, decrease in food and nutrient intake, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were implemented and documented for repositioning Resident 7 every two hours. This deficient practice had the potential to result in the resident not being repositioned as ordered, which could lead to development or worsening of pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence), and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and preferences of one of three sampled residents (Resident 13). This deficient practice had the potential to place Resident 13 at risk for decreased engagement, stimulation, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change of condition for one of three sampled Resident (Resident 7). This deficient practice had the potential to result in delayed medical evaluation, treatment and intervention, placing Resident 7 at risk of worsening conditions and adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide acceptable parameters of nutrition for one of one sampled resident (Resident 3) reviewed under nutrition care area when the facility failed to follow through with the Registered Dietitian (RD)'s recommendation to check Resident 3's hemoglobin A1C (HgA1C - a blood test that measures the average blood sugar levels over the past two [2] to three [3] months). This deficient practice had the potential to result in Resident 3 losing weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff providing care and services to a resident who had a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) utilized facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 2) reviewed for tube feeding care area by failing to ensure Resident 2's head of bed was elevated at 35 to 45 degrees at all times while receiving tube feeding. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Residents 4, 3, and 18) by: 1. Failing to ensure Registered Nurse (RN) 2 administered 20-50 milliliter (ml - unit of volume) of water after medication administration to Resident 4 as per physician's order. 2. Failing to ensure Licensed Vocational Nurse (LVN) 1 flushed (also known as rinsing) Resident 3's gastrostomy tube (g-tube, a feeding tube inserted into the stomach through the abdominal wall, used to deliver nutrition, fluids, and medications directly to the stomach when someone cannot eat or drink adequately by mouth) with water in between medication administration as per facility's policy and procedures. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%- per one hundred), four medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting two of five sampled residents (Resident's 3 and 18) observed for medication administration by: 1. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) flushed Resident 3's gastrostomy tube (g-tube, a feeding tube inserted into the stomach through the abdominal wall, used to deliver nutrition, fluids, and medications directly to the stomach when someone cannot eat or drink adequately by mouth) with water in between medication administration as per facility's policy and procedure. 2. [...]

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 the kitchen failed to label: 1 box of bacon 1 box of sausages 1 tray of eggs 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 one out of twenty medically compromised residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two (2) of (2) sampled residents (Residents 4 and 2) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Attending Physician (AP) was notified timely for one of four sampled residents (Resident 16) when Resident 16 had a change in condition. This failure resulted in delay of obtaining appropriate instructions from the AP for proper management of Resident 16's health condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure heels were floated on two pillows for one of one sampled resident (Resident 14) during a random observation. This deficient practice had the potential for Resident 14's deep tissue injury (damage to the deeper layers of the skin and underlying tissues, like muscle and fat, caused by pressure or shear forces) to reappear or form new PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accidents or hazards by failing to ensure the brakes were set on the hospital bed for one of four sampled residents (Resident 14) during a random observation. This deficient practice placed Resident 14 at risk for hazard or injury such as a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was 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 - an infection in the bladder/urinary tract) for one of five sampled residents (Resident 2) observed during the screening process by failing to keep Resident 2's urinary catheter tubing (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) from looping and allowing the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed administer total parenteral nutrition (TPN - a method of feeding that delivers nutrients directly into the bloodstream through a hollow tube, bypassing the digestive system) consistent with professional standards of practice by failing to label the TPN bag and PICC (peripherally inserted central catheter - thin, flexible tube inserted into a vein in the upper arm and guided to a large vein near the heart) line tubing with the date and time it was started on one of one resident (Resident 2) during a random screening. This deficient practice had the potential to increase Resident 2's risk for complications from TPN such as bacteria growth in the tubing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for one (1) of 1 sampled residents (Resident 9) reviewed for respiratory care by failing to ensure the Yankauer suction catheter (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when the catheter will be changed next. This deficient practice placed the resident at risk for acquiring infection from possibly contaminated equipment.

Inspectors wroteBased on observation, interview, and record review. the facility failed to maintain accurate and complete medical record for two of five sampled residents (Residents 18 and 19) by: 1. Failing to ensure Resident 18's medical record was accurate when the written order for docusate sodium (medication used to soften stool) was in soft gel (capsule) form and the electronic order was in liquid form. 2. Failed to ensure Resident 19's medical record was accurate when Licensed Vocational Nurse 7 (LVN 7) documented presence of bleeding and administered Eliquis (medication used to prevent blood clot). These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview, and record review, the facility failed to implement policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for two of five sampled residents (Resident 16 and 19) by: 1. Failing to monitor Resident 16 for antibiotic use, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled staff (Infection Preventionist [IP]) was qualified and competent in implementing the facilities infection control program by: 1. Failing to monitor Resident 16 for antibiotic (medication used to treat infection) use, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to ensure Infection Control Surveillance Log (a documented record used to systematically track and analyze healthcare-associated infections and other infectious diseases within a healthcare facility) for Resident 19's antibiotics was completely filled in 3/2025. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they have established and implemented policies in managing the facility by failing to develop and implement a policy and procedure on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition) to four out of four sampled residents (Residents 10, 13, 12, and 14) during Medication Administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference to F656 and F880.

Inspectors wroteBased on interview and record review, the facility's failed to provide care in accordance with professional standards to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. [...]

Inspectors wroteBased interview and record review, the facility failed to the facility failed to act upon the recommendations of the consultant pharmacist to two of five sampled residents investigated during review of unnecessary medications by: 1. Failing to taper (to gradually reduce dosage over time) down dosage of methadone (a powerful drug used for pain relief and treatment of drug addiction) for Resident 2. 2. Failing to indicate the behavior episodes of respiratory distress or heart rate (HR) more than (>) 120 per minute in the electronic medication administration record (eMAR) for 1 out of 5 sampled residents (Resident 17) investigated under unnecessary medications for the administration of lorazepam (a type of medication prescribed to treat conditions such as anxiety disorders [persistent and excessive worry that interferes with daily activities]. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to: 1. Store the ice scooper in a covered container when not being used. 2. Ensure Food Service Worker (FSW 1) was wearing a hairnet (a covering that will hold any dislodged hair in place, so it does not fall into the food or onto other equipment) while inside the kitchen. 3. Ensure an opened bottle of 90/10 blend canola/extra virgin olive oil was labeled with an open date and discard date. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable (capable of being passed by physical contact from one person to another) diseases and infections by failing to: 1. Ensure the barcode scanner (handheld device used to decode data contained on a barcode [a printed series of parallel bars or lines of varying width] that is then sent to a computer) was sanitized (disinfect [kill viruses and bacteria on surfaces using chemicals]) prior to use and after being placed on the resident's tablet (type of computer) for two of four sampled residents (Resident 12 and 14) observed during the Medication Administration task. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan on enhanced barrier precaution isolation (an infection control intervention designed to reduce transmission of resistant organisms) to two out of four residents (Residents 10 and 13) investigated during review of medication administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference F837 and F880.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to ensure a medication cup containing clear and white ointment was not left unattended and readily accessible in the residents' shared room for two of two sampled residents (Resident 18 and 5) observed during screening. This deficient practice had the potential to result in residents obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 1 and 2) investigated during random observations of residents with peripheral intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to label Resident 1's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm with the tip located just below the underarm) with the date of the last dressing change. 2. Failing to provide and document midline catheter care and dressing changes to Resident 2's midline catheter per facility policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during inspection of one of two medication carts (Medication Cart 2) investigated during the Medication Storage and Labeling task by failing to ensure an opened and unlabeled single-use vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) packet was not stored and readily available for use in Medication Cart #2. This deficient practice had the potential to result in topical medication being used for multiple residents with the potential for cross contamination and decreased efficacy of topical medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a mechanical, electrical, and patient care equipment in safe operational condition by failing to the ensure handheld nebulizer compressor (an electrically powered device that turns liquid medication into a fine mist for inhalation [breathing in]) was inspected by the labeled next inspection due date of 7/2023 for one of two sampled residents (Resident 18) investigated under the Respiratory care area. This deficient practice had the potential to result in delay in care and services of essential respiratory treatments for residents and had the potential for device electrical malfunction resulting in fire.