Sherman Oaks Health & Rehab

In the surveyor’s words

From the most serious findings on record at Sherman Oaks Health & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 14, 2023

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was dependent on staff for transfers and was a fall risk, was provided a safe environment and assistance to prevent accidents and injury. On 11/21/2023 at around 9:45 a.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3 manually transferred Resident 2 instead of using the assessed Hoyer lift (brand name of an assistive medical device used to transfer residents by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back) in accordance with Resident 2 ' s care plan and the facility ' s policies and procedures (P&P) on Resident Lifting / Assisting Transfer, Mechanical Lifts (devices used to assist… […]

• No harm, potential for more than minimal, patternF558Jul 2, 2026

  Based 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 for three of five sampled residents (Residents 5, 57, 31) reviewed under environment task. This deficient practice had the potential to result in a delay in care, and inability to ask for assistance when needed. Findings: 1. During a review of Resident 5's Face Sheet (FS), the FS indicated the facility admitted the resident on 9/22/2025, and readmitted the resident on 6/24/2026, with diagnoses including depression (a serious mental health condition characterized by persistent sadness, low energy, and a loss of interest in activities), aphasia (a disorder that makes it difficult to speak), and… […]

• No harm, potential for more than minimal, patternF604Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident was 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 one of three sampled residents (Resident 26) reviewed for physical restraints by failing to ensure that Resident 26's use of restraint bed placed against the wall had a current physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and a… […]

• No harm, potential for more than minimal, patternF689Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to: 1. Ensure residents were not left unattended by staff with the bed in the high / elevated position (a working height (typically that allows caregivers and nurses to perform medical tasks comfortably) for one of six sampled residents (Resident 10) reviewed for Accidents. 2. Ensure the bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was connected and functioning for one of two sampled residents (Resident 49) reviewed for Physical Restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he… […]

• No harm, potential for more than minimal, patternF760Jul 2, 2026

  Based 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 are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 5 and 38) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq- beneath the skin) insulin administration sites. […]