Sherman Oaks Hospital SNF DP

In the surveyor’s words

From the most serious findings on record at Sherman Oaks Hospital SNF DP, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF837Apr 18, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF604Apr 2, 2023

  Based on observation, interview, and record review the facility failed to ensure the resident has the right to be 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) when all side rails (SRs, also referred to as bed rails or bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were placed in raised (up) position on bilateral (two sides) upper (area including arms, shoulders and head) and bilateral lower (area… […]

• No harm, potential for more than minimal, widespreadF700Apr 2, 2023

  Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (also referred to as bed rails and bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for 18 of 19 sampled residents (Resident 17, 10, 8, 18, 6, 3, 1, 4, 14, 2, 11, 13, 12, 5, 7, 9, 15, and 16). The facility failed to: 1. Attempt to use appropriate alternatives prior to using SRs 2. Conduct an assessment including the risk for entrapment from SRs. 3. […]

• No harm, potential for more than minimal, patternF759Jun 4, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF805Jun 4, 2026

  Based 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). […]