Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sherman Oaks Health & Rehab during CMS and state inspections, most recent first.
A facility failed to keep call lights within reach for three residents who were at risk for falls and had care plans directing staff to keep the call light within easy reach. During observation, one resident’s call light was touching the floor, another resident’s call light was on the floor, and a third resident’s call light and bed remote were hanging on the side of the bed. The MDS-RN and DON stated the call lights should be within reach so the residents could call for help when needed.
A resident with stroke-related hemiplegia/hemiparesis had a bed placed against the wall, which the ADON and DON identified as a restraint. The record lacked a current MD order, informed consent, restraint assessment, and care plan, despite the resident having decision-making capacity and needing assistance with ADLs. Staff stated the restraint policy was not followed.
A facility failed to keep resident areas free of hazards when a resident was left with the bed in a high position while unattended, another resident’s bed pad alarm was disconnected and not working, and a smoker with dementia had cigarettes and a lighter left in the room without supervision. Surveyors also found frayed wires on a bed remote, equipment placed on top of floor mats, and medications left at a bedside table, all contrary to the residents’ care plans and safety precautions.
Failure to Rotate Insulin Injection Sites: Two residents receiving insulin had repeated subcutaneous injections documented in the same abdominal quadrants despite orders to rotate sites. The MDS-RN and DON stated the pattern did not follow the residents’ insulin orders, the facility’s insulin administration policy, or manufacturer guidance, and identified the practice as a medication error.
Medication carts contained multiple storage and labeling errors. Two residents’ Artificial Tears were labeled only with room numbers, two residents’ prepared meds were left in unlabeled cups in the cart when they were not available, germicidal wipes were stored next to resident meds and one container had spilled, and a floor stock multivitamin bottle was open without an open date. The DON and LPNs stated these practices did not follow facility policy.
Inaccurate MAR Documentation for Held Metoprolol: A resident with ESRD, HTN, and dialysis dependence had an order for Metoprolol with hold parameters for low SBP or HR, but the MAR showed the medication as given even though it was held on multiple occasions when BP readings were below the ordered limits. The IP nurse stated the entries were likely documentation errors and that the medication had not been administered, while the ADON and DON confirmed the charting did not reflect the ordered parameters or the facility’s documentation policy.
The facility failed to keep resident equipment in safe condition when two residents’ bed remote controls were observed with frayed wires and another resident’s bedside fan had dust buildup on the blades and grill. The residents involved had care plans for a safe environment, and facility staff including an LVN, CNA, MDS-RN, and DON acknowledged the exposed wiring and dirty fan were not acceptable under the facility’s Maintenance Service policy.
A resident on hospice had PRN lorazepam orders without required stop dates, including an order that remained indefinite despite a pharmacist review noting PRN psychotropics are limited in duration unless the prescriber documents otherwise. Another resident with anxiety, depression, and mood disorder received Klonopin for anxiety and panic symptoms without documented informed consent in the chart, and the MDS RN and DON stated the consent could not be found and should have been obtained before administration.
A resident with a right heel diabetic ulcer, right shin vascular ulcer, and other pressure injuries was observed wearing a right foot heel protector, but the chart contained no order for it and the care plan did not include it. The OSR showed wound treatment orders for the heel ulcer, while the MDS-RN and DON stated staff should have obtained a provider order and informed the physician before applying the heel protector. The DON also stated the care plan was not updated to reflect the intervention and that staff did not follow the facility’s treatment order policy.
Failure to Secure Foley Catheter Tubing: A resident with a Foley catheter and diagnoses including UTI, sepsis, and bacteremia had an order for catheter tubing to be secured every day shift, but during observation the tubing was not secured to the leg strap or stat lock. The CNA, MDS-RN, and DON all acknowledged the catheter should have been secured with a device to prevent friction, tugging, and meatal irritation, and facility policy required the catheter to remain secured with an approved securement device.
A resident with a peripheral IV had a dressing that was not labeled with the nurse’s time and initials, despite facility policy requiring the date, time, and initials on the dressing label. Another resident with a PICC and TPN had a y-injection site left open to air without a Curos cap, even though staff stated all ports should be covered and the facility policy called for a needless access device and a closed system.
A resident with acute respiratory failure, COPD, and pneumonitis was observed receiving O2 at 10 LPM via face mask without a humidifier attached. RN, MDS-RN, and DON all stated the humidifier should have been used because the order allowed oxygen without humidification only below 5 L/min, and the facility's oxygen policy recommended a humidifier bottle for flow rates above 5 L/min.
Incorrect Bed Rail Size Applied for Two Residents: The facility failed to follow physician orders for bed rails by using bilateral upper 1/4 side rails instead of ordered bilateral upper 1/2 side rails for two residents. One resident had stroke-related weakness, impaired mobility, and a history of falls; the other had dementia, functional quadriplegia, and severe cognitive impairment. Observations confirmed the 1/4 rails were in place, and the MDS-RN and DON stated the applied rails did not match the orders, assessments, consent, or care plans.
A resident with Parkinson's disease, chronic pain, OA, and neuropathy had PRN hydrocodone-acetaminophen ordered for severe pain, but two doses removed from the bubble pack were not documented in the MAR. Staff stated the process was to record the removal, administer the medication, and then document it in the MAR, but one LPN acknowledged failing to document administration. The DON stated the MAR is proof a narcotic was given and noted the missing documentation left no record that the doses were administered or followed up on.
Failure to monitor anticoagulant therapy for adverse effects: A resident receiving Eliquis via G-tube for DVT prophylaxis had a care plan identifying risk for adverse effects, but the chart lacked an order to monitor for bleeding or other adverse reactions. The MDS-RN and DON stated the monitoring required by the facility’s anticoagulation protocol and the Eliquis prescribing information was not in place, and staff did not communicate the missing monitoring order.
A resident with stroke-related diagnoses and intact decision-making capacity lost his upper dentures in the facility and was charged $800 for replacement. The resident said he filed a grievance after being told to pay for the dentures, while SS confirmed the dentures were listed in his inventory and the facility could not locate them. The DON stated the resident should not have been required to cover the cost because the dentures were misplaced in the facility.
An LVN handled a resident’s inhaler box by placing it on the resident’s bedside table and then returning it to the med cart with other residents’ meds, contrary to facility infection control practices. In a separate issue, a resident’s urinal was found unlabeled with the resident’s name and date, despite facility policy requiring labeling of reusable resident care items. The DON and CNA stated both practices could lead to cross contamination.
Failure to Monitor Adverse Effects of IV Antibiotics: The facility did not fully implement its antibiotic stewardship program for two residents receiving IV antibiotics for sepsis and other infections. Nursing notes showed missing adverse effect monitoring for Ampicillin, Cefepime, and Meropenem, and the MDS-RN, IP, and DON stated antibiotics should be monitored every shift and documented in progress notes, but the facility’s surveillance tracking form did not include adverse effects.
A resident with osteoporosis, dementia, and hypertension, and with moderately impaired cognition, had a care plan and MD order for a low air loss mattress (LALM) to prevent pressure ulcers. Surveyors observed the LALM made with a fitted sheet, two cloth chux, and a disposable brief, contrary to facility practice and staff statements that only one sheet and one chux or brief should be used. An LVN and the DON explained that extra linen layers interfere with air circulation and can create pressure and friction, and a CNA acknowledged placing two chux under the resident. This was inconsistent with the facility’s support surface guidelines for PU prevention.
A resident with diabetes and other comorbidities, who was oriented and knowledgeable about her medications, reported that an LVN brought an insulin pen labeled with another resident’s name to her bedside and placed it on her tray table. The resident noticed the incorrect name on the pen, informed the LVN, and photographed the pen, after which the LVN removed it and returned with insulin pens labeled for the correct resident and administered the insulin. The LVN later stated she had placed an expired insulin pen for another resident and the correct resident’s insulin pen on top of the medication cart and mistakenly picked up the wrong pen when bringing medications into the room, contrary to facility policy and standard practice requiring verification of the five rights and preparation of medications for only one resident at a time.
A resident with DM2, morbid obesity, and HTN had orders for basal and sliding-scale insulin. One evening, an LVN preparing medications placed multiple residents’ insulin pens on top of the med cart and inadvertently brought an insulin pen labeled for another resident into the room, placing it on the bedside tray. The alert resident recognized the wrong name on the pen, informed the LVN, and the LVN then retrieved and used the correct insulin pen. The LVN later acknowledged she had mistakenly grabbed the other resident’s pen and also acknowledged that she did not document this medication error in the medical record, despite facility policies and nursing staff statements that all medication errors and related incidents must be charted. Review of the record confirmed there was no nursing note about the incident, resulting in an incomplete clinical record for the resident.
A resident with intact cognitive skills reported that a visitor used inappropriate language towards her, which staff recognized as verbal abuse. Although the incident was reported to staff, a miscommunication prevented the administrator from being fully informed, resulting in a failure to notify the State Survey Agency, ombudsman, and law enforcement within the required two-hour timeframe. This delay led to a late investigation and potentially placed the resident at risk.
A resident's EHR containing sensitive medical information was left open and unattended at a nurses' station, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use, and facility policy mandates that computer terminals be shielded and logged off when unattended. This failure resulted in a breach of privacy and confidentiality for the resident's protected health information.
A resident with hemiplegia and high fall risk, dependent on staff for transfers and requiring a mechanical lift with two-person assistance, was transferred by staff without the required lift. Following the transfer, the resident developed new leg pain, swelling, and bruising, and was later diagnosed at a hospital with a left knee fracture. Staff interviews confirmed the transfer was performed improperly and not in accordance with facility policy.
Two medication carts were found open and unattended in a nurses' station, as confirmed by the DON during an interview. Facility policy requires medication carts to be locked when out of staff view, but this was not followed, creating the potential for unauthorized access to medications.
CNAs failed to accurately and timely document the percentage of food consumed by three residents with severe cognitive impairments and complex medical conditions. Meal intake records were often incomplete, missing, or recorded at incorrect times, leading to inaccurate medical records. Facility leadership confirmed that documentation did not meet professional standards or facility policy.
A resident with moderate risk for pressure ulcers and impaired mobility was found to have a low air-loss mattress set incorrectly at 160 lbs, despite weighing 115 lbs. Staff interviews and record reviews confirmed the mattress should have been set to 120 lbs according to the resident's weight and manufacturer guidelines. This failure to follow professional standards and facility policy placed the resident at risk for pressure ulcer development.
The facility failed to obtain proper informed consent for psychotropic medications for several residents, including those with major depressive disorder and dementia. Incomplete consent forms lacked signatures from residents or their representatives and prescribing physicians, leading to the administration of medications without documented consent. This oversight was acknowledged by the facility's RN and DON, highlighting a failure to follow policy and potentially resulting in the use of unnecessary psychotropic drugs.
The facility did not make the most recent survey results accessible to residents and their representatives, as required by policy. Residents were unaware of where to find the survey results, and the binder was not visible or up-to-date. The Administrator confirmed the importance of making these results available, but the facility failed to comply with its own policy.
The facility failed to follow proper protocols for the use of restraints on two residents. A resident had a bed alarm applied without a restraint assessment, physician's order, informed consent, or care plan, while another resident had pillows tucked under the fitted sheet as a restraint without the necessary documentation and approvals. These actions did not comply with the facility's policy on restraint use, which requires thorough assessment and documentation.
Two residents in an LTC facility did not receive proper monitoring for medication side effects and effectiveness. One resident, on blood thinners for atrial fibrillation, was not monitored for bleeding, while another, on atorvastatin for hyperlipidemia, did not have lipid levels checked. The facility's policies required such monitoring, but it was not documented.
The facility's nursing staff failed to rotate insulin injection sites for three residents, leading to a deficiency in care. Despite physician's orders and guidelines, insulin was repeatedly administered in the same areas, risking adverse effects. The DON and RN acknowledged the oversight and the importance of site rotation to prevent skin complications.
The facility failed to maintain a safe environment for residents, leading to multiple deficiencies. A resident at high risk for falls had floor mats obstructed by equipment, compromising their effectiveness. Another resident's room had environmental hazards like protruding nails, and a third resident was left unattended in a high bed position during wound care, increasing fall risk. These actions violated facility policies aimed at ensuring resident safety.
The facility failed to properly administer and document oxygen therapy for residents requiring respiratory care. A resident with metabolic encephalopathy and dementia received oxygen therapy without consistent documentation on the MAR. Another resident with Alzheimer's Disease also received oxygen therapy without proper documentation and monitoring. Additionally, a resident's oxygen tubing was observed touching the floor, posing a risk of infection. These deficiencies could lead to respiratory distress and infections.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, as required by their care plan and facility policy. The resident, dependent on hemodialysis, had multiple instances where post-HD assessments were not documented, potentially delaying care and detection of complications. Interviews confirmed the importance of these assessments, yet documentation was incomplete despite regular staff training.
A facility failed to account for three doses of controlled medications for three residents, leading to a deficiency in pharmaceutical services. An LVN admitted to administering the medications but did not document the administration on the accountability logs, violating facility policy. This lack of documentation increased the risk of medication errors and potential harm to the residents, who required these medications for chronic pain, pressure ulcers, and neuropathy.
A CP failed to report irregularities in drug regimen reviews for two residents, leading to deficiencies in monitoring for adverse effects of medications. One resident on blood thinners was not monitored for bleeding, and another on atorvastatin was not monitored for lipid levels. The DON acknowledged the lack of documentation, and the CP admitted to missing these issues in reviews.
A facility failed to monitor drug regimens and side effects for three residents, leading to potential unnecessary drug use. One resident on Eliquis, clopidogrel, and gabapentin lacked monitoring for bleeding and drug toxicity. Another resident on atorvastatin had no lipid panel conducted since admission. A third resident on apixaban lacked monitoring for adverse effects. The facility's policies emphasized the need for such monitoring to prevent harm.
The facility failed to ensure appropriate use of psychotropic medications for several residents, including administering lorazepam without proper documentation, prescribing mirtazapine and divalproex without specific target behaviors, and administering sertraline and divalproex sodium without informed consent. Additionally, alprazolam was prescribed PRN without a stop date, leading to potential unnecessary medication use.
A facility failed to maintain a medication error rate below five percent, resulting in a 12.5% error rate. Two residents experienced errors: one received carvedilol at the wrong time, an incorrect multivitamin, and missed polyethylene glycol; another received carvedilol late. LVNs cited being busy as the cause. The facility's policy requires medications to be administered within a 60-minute window, which was not followed.
The facility failed to rotate insulin injection sites for three residents, leading to significant medication errors. Despite physician's orders and guidelines, insulin was repeatedly administered in the same areas, risking adverse effects. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to update its staffing plan, resulting in medication administration delays for two residents. LVNs were assigned more residents than the assessed ratio of 1 LVN to 24 residents, leading to late administration of carvedilol. The facility's assessment had not been updated since 12/1/2024, despite changes in resident acuity.
The facility failed to maintain an effective infection prevention and control program by using permeable linen cart covers, which allowed contamination from dust and liquids. Observations and interviews revealed that all 17 linen carts were covered with unsuitable materials, and the cleaning methods used were not aligned with the manufacturer's guidelines or facility policies. This deficiency had the potential to spread infections among residents and staff.
A resident with a DNR order was mistakenly given CPR after being found unresponsive due to a failure in filing the correct documentation in their current chart. The oversight led to the assumption that the resident was full code status, resulting in a violation of their rights to dignity and respect.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating resident needs. One resident with dementia and a history of falls had the call light hanging on the wall, while another alert and oriented resident had the call light on the floor. Staff acknowledged the oversight and confirmed the importance of having call lights accessible to ensure timely responses to residents' needs.
The facility failed to assist two residents with formulating Advance Directives (ADs) upon admission, despite their severe cognitive impairments and need for assistance with daily activities. The facility's records lacked documentation of any inquiry or assistance offered to the residents' representatives regarding ADs, contrary to the facility's policy. Interviews confirmed that necessary steps were not taken, potentially impacting the residents' care in emergencies.
The facility failed to maintain a safe and homelike environment for two residents. One resident had a damaged floor mat that was not replaced, despite being at high risk for falls. Another resident's room had a broken baseboard and windowsill with exposed nails and debris, and unrelated red letters on the wall, creating an unsafe and institutional setting. These conditions were not in line with the facility's policy for a homelike environment.
A facility failed to provide a written notice of the bed-hold policy to a resident's representative during a hospital transfer. The resident, with diagnoses including metabolic encephalopathy and sepsis, was transferred due to medical issues, but the required notification was not given, as confirmed by staff interviews. This oversight could lead to the resident being moved to a non-preferred facility.
A resident with a documented DNR order was administered CPR after being found unresponsive, due to a failure in filing the resident's PIC Authorization/Decisions form in the current chart. The oversight led staff to consider the resident as full code status, resulting in a violation of the resident's rights and preferred treatment wishes.
A resident with significant medical conditions was transferred to a hospital due to elevated WBC and BUN levels, but the facility failed to perform a required change of condition assessment. This omission was confirmed by staff interviews and contradicted the facility's policy, potentially impacting the resident's care.
Call lights not kept within reach for three residents
Penalty
Summary
The facility failed to keep call lights within reach for three sampled residents who were assessed as being at risk for falls and who had care plans directing staff to keep the call light within easy reach and encourage use for assistance. During observation, Resident 5’s call light was found touching the floor on the left side of the bed, Resident 57’s call light was on the floor on the right side of the bed, and Resident 31’s call light and bed remote control were hanging on the right side of the bed. In each instance, staff acknowledged that the call light was not positioned so the resident could readily use it. Resident 5’s record showed diagnoses including depression, aphasia, and lack of coordination, with moderately impaired vision, moderately impaired cognitive skills, dependence for mobility and ADLs, and a fall risk evaluation identifying the resident as at risk for falls. Resident 57’s record showed diagnoses including weakness, visual loss, and history of falling, with severely impaired vision, severe cognitive impairment, and dependence to needing partial assistance with mobility and ADLs, along with a fall risk evaluation identifying the resident as at risk for falls. Resident 31’s record showed diagnoses including a healing fracture of the lower end of the right radius, other lack of coordination, and history of falling, with moderate cognitive impairment, dependence or maximal assistance with mobility and ADLs, and a fall risk evaluation identifying the resident as high risk for falls. The MDS-RN and DON reviewed the records and stated that each resident’s call light should be within reach so the resident could call for help when needed. They also stated that the residents were at risk for falls and could fall while reaching for a call light that was on the floor or otherwise not within reach. The facility’s policy titled Call System, Residents, stated that residents are provided with a means to call staff for assistance from the bed, toileting/bathing facilities, and from the floor.
Bed Against Wall Used Without Required Restraint Documentation
Penalty
Summary
The facility failed to ensure that Resident 26 was free from the use of a physical restraint when the resident’s bed was placed against the wall without a current physician’s order, informed consent, restraint assessment, or care plan. Resident 26’s record showed a history of hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, tobacco use, and cramp and spasm. The resident’s H&P stated the resident had the capacity to understand and make medical decisions, and the MDS indicated the resident could make self-understood and understand others, with assistance needed for oral and personal hygiene, toileting, bathing, and transfers. During observation, Resident 26 stated the bed was adjacent to the wall and that the resident had limited range of motion to the left upper and lower extremities due to stroke. The IP nurse confirmed that the left side of the bed was placed against the wall. The ADON reviewed the record and stated there was no assessment, consent, doctor’s order, or care plan for the bed placed against the wall, and stated that if a bed is placed against the wall it is considered a restraint. The ADON also stated the resident could possibly hurt himself if limbs got caught. The DON likewise stated that when a bed is placed against the wall, it is considered a restraint and that there must be an assessment, consent, MD order, and care plan before placing the bed against the wall. The DON stated the restraint policy was not followed. The facility policy required restraints only after other alternatives failed, a pre-restraint assessment, a written physician order, consent from the resident or representative, and care plans reflecting interventions and measures to reduce or eliminate restraint use.
Unsafe Resident Environment and Supervision Failures
Penalty
Summary
The facility failed to maintain a safe environment when Resident 10 was observed lying in bed with the bed in a high, elevated position and no staff in the room. The resident had diagnoses including Parkinson’s disease, chronic pain syndrome, osteoarthritis, and dementia, and was identified in the facility’s fall prevention program with a high fall risk score. Staff later acknowledged that the bed should not have been left in the high position after care was provided, and the resident stated she did not know how to lower the bed and wanted it in the low position so she would not fall if she needed to get up. The facility also failed to ensure a bed pad alarm was connected and functioning for Resident 49, who had diagnoses including CVA, dementia, glaucoma, hearing loss, and a history of falling. The resident had an order for a bed pad alarm due to episodes of getting up unassisted, and the care plan directed staff to apply the alarm and monitor it for proper placement and working condition. Surveyors observed the alarm not sounding when the resident shifted in bed, and later found the cord between the pad and alarm box disconnected. Staff stated the alarm should have been functioning, but it was not, and acknowledged the resident was a fall risk. Resident 117, who had dementia, tobacco use, noncompliance with medical treatment, and traumatic brain injury, was supposed to smoke only with supervision and have no access to matches or lighters. Despite this, surveyors observed a pack of cigarettes and a lighter on the resident’s bedside table and later observed cigarettes still in the room while no staff were present. The resident’s care plan required supervision while smoking, and staff stated the resident should not have cigarettes or a lighter in the room. The report also documented Resident 5 with frayed wires on the bed remote control, and Resident 48 and Resident 31 with equipment or furniture placed on top of floor mats that were intended to reduce injury from falls. In addition, Resident 103 had medications or biologicals left at the bedside table, which was identified during the survey as another unsafe condition.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that two sampled residents receiving insulin were free from significant medication errors because licensed nurses did not rotate subcutaneous insulin administration sites as ordered. For Resident 5, the record showed orders for insulin glargine, insulin lispro, and semaglutide with instructions to rotate injection sites. The location-of-administration record showed multiple insulin doses given repeatedly in the same abdominal quadrant, including several consecutive administrations in the left lower quadrant, left upper quadrant, and right lower quadrant. Resident 5’s record also showed diagnoses including type 2 diabetes mellitus with hyperglycemia, gastrostomy, and dysphagia. The history and physical indicated the resident had the capacity to understand and make decisions, while the MDS noted moderately impaired cognition and moderately impaired vision. During interview and record review, the MDS-RN and DON stated that insulin sites should be rotated to prevent repeated injections in the same area and that the documented pattern showed multiple instances where staff did not rotate the sites. They stated the nurses could view prior injection sites in the eMAR before administering insulin, and that failing to rotate the sites was considered a medication error because it did not follow the physician’s order, manufacturer’s specifications, and professional standards. For Resident 38, the record showed diagnoses including type 2 diabetes mellitus, protein-calorie malnutrition, and dysphagia. The resident had capacity to understand and make decisions, and the MDS indicated intact cognition. Orders for Admelog and Lantus included instructions to rotate injection sites. The location-of-administration record showed repeated insulin administrations in the same abdominal quadrants on multiple occasions, including repeated use of the left upper quadrant, right lower quadrant, and right upper quadrant. During interview and record review, the MDS-RN and DON stated the repeated use of the same insulin sites did not follow the resident’s orders, the facility’s insulin administration policy, or the manufacturer’s specifications, and they identified the failure to rotate sites as a medication error.
Medication Labeling and Storage Failures on Medication Carts
Penalty
Summary
The facility failed to ensure safe handling and storage of medications on multiple medication carts. During observation of Medication Cart 3/AM, two boxes of Artificial Tears for two residents were labeled only with room numbers and not with the residents’ names. The LVN stated the names should have been written on the eye drops because room numbers can change, and the DON confirmed the facility’s policy was not followed. The residents involved included one with macular degeneration and another with dry eye syndrome, and both had orders for Artificial Tears ophthalmic solution to be instilled in both eyes three times daily. The facility also stored prepared medications in unlabeled medication cups inside the cart for two residents. One cup contained sertraline, propranolol, amlodipine, and losartan for one resident, and the other contained folic acid, acetaminophen, divalproex sodium, and lisinopril mixed with applesauce for another resident. The LVN stated she had removed the medications from bubble packs and placed them in cups when the residents were not available, and then stored them in the medication cart. The DON stated the facility process was to administer medications for one resident at a time and that prepared medications should not be stored in the cart when a resident is unavailable. The inspection also found germicidal disinfectant wipes stored in drawers next to resident medications on two medication carts, including one instance where the wipes container was on its side and had spilled into the drawer. The LVNs stated chemicals should not be mixed with medications, and the DON stated disinfectant wipes are stored separately because they may leak or spill and contaminate medications. In addition, a floor stock bottle of Multivitamins with Minerals was observed on a medication cart without an open date. The LVN and MDS-RN stated the bottle needed an open date, and the DON confirmed the facility policy required an open date when multi-dose containers are opened.
Inaccurate MAR Documentation for Held Metoprolol
Penalty
Summary
The facility failed to properly document Resident 8’s medication administration record when Metoprolol was charted as given on 6/14/2026, 6/15/2026, and 6/27/2026 even though the medication was held. Resident 8 was admitted on 4/24/2026 with diagnoses including ESRD, dependence on renal dialysis, HTN, sleep apnea, and depression. The history and physical dated 4/30/2026 stated the resident did not have memory loss and had the capacity to make medical decisions, while the MDS dated 5/5/2026 indicated moderate cognitive impairment and need for assistance with several activities of daily living. Resident 8 had an order dated 4/27/2026 for Metoprolol Succinate ER 25 mg daily for essential hypertension, with parameters to hold for SBP less than 110 or heart rate less than 60 and to give with food. The care plan identified the resident as at risk for cardiac distress related to ESRD with HTN and Metoprolol use, and the Falling Star Program care plan identified risk for falls related to antihypertensive medications. During record review and interview, the IP nurse stated the medication was documented as given on the three dates even though the BP readings were below the ordered parameters, and stated it was likely a documentation error and that he was certain the medication had not been administered. The IP nurse stated that when SBP is below 110, the medication must be held and documented as held with an explanation in the progress notes and nurses’ initials on the MAR. The ADON stated the parameters were established to ensure the medication is withheld if blood pressure readings are low, and that the documentation indicated the medication was administered, which could have placed the resident at risk for hypotension. The DON stated the order with parameters was the basis for whether the medication should be given or held, that the IP nurse had signed the medication as given but could not confirm whether it had actually been administered, and that the facility’s charting and documentation policy was not followed.
Unsafe Resident Equipment and Environmental Maintenance
Penalty
Summary
The facility failed to maintain resident care equipment and electrical equipment in safe operating condition for three sampled residents. During observation and interview, Resident 38’s bed remote control was found with frayed wires, and Resident 53’s bed remote control was also observed with frayed wires. Both residents had care plans that included providing a safe environment free of hazards. Resident 38 had diagnoses including cerebral infarction and a history of falling, had impaired vision, and was assessed as having intact cognition and being at risk for falls. Resident 53 was admitted with lack of coordination, generalized anxiety disorder, and depression, and was assessed as having moderate cognitive impairment. For Resident 38, the frayed wires were observed in the resident’s room while the resident’s bed remote control was in use. LVN 3 stated there should be no open wires in the resident’s environment because of the potential for electrocution and because the bed might not work properly. The MDS-RN stated exposed electrical wires were not acceptable in the resident’s environment and identified maintenance as responsible for ensuring there were no frayed or open wires. The DON also stated there should be no frayed wires in the resident’s room and that staff should report hazards such as exposed electrical wires to maintenance. For Resident 63, the bedside electric fan was observed running with dust buildup on the fan blades and protective grill. Resident 63 had diagnoses including dementia and functional quadriplegia, did not have capacity to understand and make decisions, and had severely impaired cognitive skills. CNA 9 stated the fan was not clean and had dust buildup. The MDS-RN stated the fan should be free from dust buildup at all times, and the DON stated the fan should not have dust buildup and that staff should check the resident environment for hazards, cleanliness, and functional equipment and appliances. The facility’s Maintenance Service policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment, and that maintenance personnel are responsible for keeping buildings, grounds, and equipment in a safe and operable manner at all times.
Unnecessary Psychotropic Medication Orders and Missing Informed Consent
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders for a resident on hospice included a stop date and were limited to the required duration. Resident 83 was admitted with diagnoses including cirrhosis of the liver, anxiety disorder, Wernicke encephalopathy, and traumatic brain injury. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident usually understood others and usually could make herself understood and received high-risk antianxiety drugs. Resident 83 had physician orders for lorazepam 0.5 mg by mouth every 6 hours as needed for anxiety-related symptoms. One order dated 3/12/2026 had no stop date and was later discontinued on 5/11/2026. Another order dated 6/22/2026 also had an indefinite stop date. The consultant pharmacist’s medication regimen review dated 3/18/2026 noted that PRN psychotropic drugs are limited to 14 days unless the prescriber documents a rationale and duration, and the review identified the resident’s PRN lorazepam order as needing a stop date. During interview, the MDS RN stated PRN psychotropic medications must have a stop date and be re-evaluated by the physician, and that the resident’s PRN lorazepam orders did not include the required stop dates. The facility also failed to obtain informed consent before administering Klonopin to Resident 74. Resident 74 had diagnoses including anxiety disorder, depression, and mood disorder, and the H&P stated the resident did not have the capacity to understand and make decisions. The OSR showed an order for Klonopin 0.5 mg, 0.5 tablet by mouth twice daily for anxiety and panic symptoms, and the care plan identified the resident as at risk for adverse effects from Klonopin. During interview, the MDS RN stated she could not find informed consent for Klonopin in the electronic record or paper chart and stated the medication should not have been given without informed consent. The DON stated the staff administered the psychotropic medication without the resident’s or representative’s consent and that the facility did not follow its informed consent policy.
Failure to Obtain Order for Heel Protector on Resident with Foot Ulcer
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided for a resident with multiple wounds, including a right heel diabetic ulcer and a right shin vascular ulcer. The resident was admitted with diagnoses including cellulitis of the right lower limb, peripheral vascular disease, and a stage 3 sacral pressure ulcer. The resident’s H&P documented a stage 4 decubitus ulcer on the right heel, and the MDS indicated the resident had moderate cognitive impairment, was mostly dependent for mobility and ADLs, and was at high risk for pressure injury development. The resident’s OSR showed an order for Santyl to the right heel with cleansing, calcium alginate, and dry dressing, but there was no order for a right foot heel protector. The Braden Scale did not indicate an intervention to apply a right foot heel protector, and the care plan for wound/skin integrity impairment did not include application of a right foot heel protector. During observation, the resident was seen with a right foot heel protector in place, and the Infection Preventionist stated the resident had skin issues on the right foot and that was why the heel protector was on. During interview and record review, the MDS-RN stated she could not find an order for the right foot heel protector and that licensed nurses should have obtained an order and informed the physician before applying it because it involved the resident’s diabetic and venous wound ulcers. The DON also stated staff should have obtained an order and informed the physician of the application of the right foot heel protector, and that the care plan should have been updated to reflect the intervention. The DON stated the licensed staff did not follow the facility policy on medication and treatment orders, which requires treatments to be administered only upon a written order from an authorized prescriber.
Failure to Secure Foley Catheter Tubing
Penalty
Summary
The facility failed to ensure that Resident 5’s urinary catheter was secured with a leg strap or stat lock as ordered. Resident 5 was admitted and later readmitted with diagnoses including UTI, sepsis, and bacteremia. The resident’s records showed an order to secure the Foley catheter tubing with an anchor every day shift and to provide Foley catheter care every day shift. The care plan also identified an alteration in urinary elimination and risk for UTI related to the Foley catheter, with catheter care to be provided every shift or as ordered. During a concurrent observation and interview, Resident 5 was seen with a leg strap in place, but the catheter tubing was not secured to it. The CNA stated the catheter tubing should always be secured with a leg strap to prevent accidental dislodgement. During later review and interview, the MDS-RN stated there was an order to secure the Foley catheter with an anchor every day shift and acknowledged the catheter was not secured to a leg strap. The MDS-RN stated this created a potential for the tubing to be tugged or pulled, which could result in meatal tear and provide a portal of entry for infection leading to UTI. The DON also reviewed the resident’s care plan and the facility’s urinary catheter policies and stated the catheter should always be secured with a securement device such as a leg strap to prevent friction and irritation at the meatal opening. The DON stated failure to secure the catheter could lead to the catheter being pulled out, pain and bleeding at the insertion site, and infection due to reinsertion. The facility policies reviewed stated that catheter tubing and/or bag should be secured with an approved securement device and that the catheter should remain secured to reduce friction and movement at the insertion site.
IV Dressing Labeling and PICC Port Coverage Failures
Penalty
Summary
Resident 74 had a peripheral IV in the left forearm that was dated 6/28/2026, but during observation the IV dressing did not have the time or the initials of the licensed nurse who inserted the IV or changed the dressing. The resident’s record showed admission and readmission information, diagnoses including UTI, diaphragmatic hernia, and a personal history of venous thrombosis and embolism, and an H&P stating the resident did not have the capacity to understand and make decisions. The MDS indicated moderate cognitive impairment and that the resident was on a high-risk antibiotic drug class. The resident’s OSR included orders for peripheral site care as needed for complications, extension of the IV site for poor venous access if no complications were present, dressing changes with site changes and PRN, and peripheral site care every 72 hours. During the observation, RN 1 stated the peripheral IV should be dated, timed, and initialed by the nurse who inserted or changed the dressing so the timing of IV replacement or dressing change would be known and to help prevent infection. The MDS-RN later stated the peripheral IV care should have the date, time, and initials whenever staff insert or change the dressing, and that the line should be rotated as needed. The facility’s P&P titled Peripheral Venous Catheter Insertion stated to write the date, time, and initials on the dressing label, and the Peripheral Catheter Dressing Change policy stated to label the dressing with the date, time, and nurse’s initials. The DON stated the dressing should have been dated, timed, and initialed to know how old the peripheral IV was and when to change the dressing to prevent infection at the insertion site, and stated the policies were not followed by licensed staff. Resident 126 had a PICC line with two lumens and TPN infusing through tubing attached to one lumen. During observation, the y-injection site was open to air and touching the bedsheet, and it did not have a Curos cap. The resident’s record showed diagnoses including streptococcal sepsis, pneumonitis, severe sepsis, and chronic cough, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident was dependent for all ADLs including transfers. The resident’s care plan addressed infection and complications related to the PICC line and included interventions for aseptic handling, hand hygiene, standard precautions, and dressing changes every seven days and PRN. The OSR ordered daily central line and midline care, transparent dressing changes per sterile technique, and changing the injection cap to each lumen and the securement device. The ADON stated the y-injection site should have been closed with a green cap and that the policy was not followed. The IP nurse stated all ports should be covered with a green Curos cap to prevent CLABSI, and the DON stated all ports should be covered with a Curos cap to maintain a closed system and prevent bloodstream infections. The facility’s P&P stated a needless access device would be used at the hub of all venous access devices, disinfecting caps were for needless connectors, and every attempt would be made to maintain a closed system.
Failure to Use Humidifier With High-Flow Oxygen
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice for one sampled resident receiving oxygen therapy. The resident had diagnoses including acute respiratory failure, COPD, and pneumonitis, and the record showed an order allowing oxygen without a humidifier only when the oxygen flow rate was less than 5 L/min, along with an order to change the humidifier as needed when consumed. The care plan also directed staff to provide oxygen as ordered and observe for safety when using oxygen. During a concurrent observation, interview, and record review, the resident was observed receiving oxygen at 10 LPM via face mask without a humidifier attached to the oxygen setup. RN 1 stated the humidifier should have been attached because the oxygen was running above 5 LPM. The MDS-RN and DON also stated the humidifier should have been used with oxygen at 10 LPM, and both referenced the physician order and facility policy indicating a humidifier bottle was recommended for oxygen flow rates above 5 L/min. The DON stated the licensed staff did not follow the facility's oxygen administration policy by failing to attach a humidifier for the resident's high-flow oxygen.
Incorrect Bed Rail Size Applied for Two Residents
Penalty
Summary
The facility failed to follow physician orders for bed rails for two residents by applying bilateral upper 1/4 side rails instead of the ordered bilateral upper 1/2 side rails. For Resident 38, the record showed admission with diagnoses including hemiplegia, hemiparesis, ankle contractures, and a history of falling. The resident was documented as having the capacity to understand and make decisions, intact cognition, and impairment of one upper extremity and both lower extremities. The order summary indicated bilateral upper half siderails with padding as a nonrestraint to increase independence with self-positioning due to decreased strength related to status post stroke, with informed consent obtained after explanation of risks and benefits. Resident 38’s fall risk evaluation identified the resident as at risk for falls, and the care plan included interventions related to the use of the bilateral upper half siderails with padding and prevention of leaning forward due to poor trunk control. During observation, the resident was seen with bilateral upper 1/4 side rails up and padded. The Maintenance Director confirmed the resident had bilateral 1/4 side rails and stated the facility did not have 1/2 bedrails or full bedrails available. The MDS-RN reviewed the records and stated the applied side rails were bilateral 1/4 bed rails and did not follow the physician’s order, and that the assessment, consent, and care plan were completed for bilateral 1/2 side rails rather than the 1/4 side rails actually in use. For Resident 63, the record showed diagnoses including dementia, age-related cataract, and functional quadriplegia. The resident was documented as lacking capacity to understand and make decisions, with severely impaired cognition and dependence or substantial assistance needed for mobility and ADLs. The order summary indicated a low bed with bilateral upper siderails up to decrease potential injury due to unpredictable movement/behavior related to dementia, and the fall risk evaluation identified the resident as at risk for falls. During observation, the resident was seen with bilateral upper 1/4 side rails up. The MD confirmed the resident had bilateral 1/4 side rails and stated the facility did not have 1/2 bedrails or full bedrails available. The MDS-RN stated the applied side rails did not match the physician’s order, and that the assessment, consent, and care plan were completed for bilateral 1/2 side rails rather than the 1/4 side rails actually used. The DON stated licensed staff should have followed the physician’s order for bilateral 1/2 bed rails and notified leadership of their unavailability, and stated the staff did not follow the facility’s Bed Safety and Bed Rails policy.
Controlled Substance Doses Not Documented as Administered
Penalty
Summary
The facility failed to account for two doses of hydrocodone-acetaminophen for a resident with Parkinson's disease, chronic pain syndrome, osteoarthritis of the left shoulder and right knee, and neuropathy. The resident was admitted with the capacity to make medical decisions and was documented as needing assistance with bathing, dressing, toileting, and personal hygiene, and as receiving PRN opioids for pain management. The physician order was for hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every eight hours as needed for severe pain. During review of the resident's controlled drug record and medication administration record, staff identified that a dose removed from the bubble pack on 5/4/2026 at 5:22 p.m. was not documented as administered in the MAR, and another dose removed on 5/5/2026 at 2:00 p.m. was also not documented as administered in the MAR. One LVN stated the facility process was to remove the medication from the bubble pack, sign the controlled drug record, administer the medication, and then document the administration in the MAR. Another LVN stated he removed the hydrocodone-acetaminophen on 5/5/2026 but did not document that it was administered in the MAR, although he should have. The DON reviewed the records and stated the MAR is proof that a narcotic was given and is used by licensed nurses to know when pain medication may be given next. The DON stated the facility process for PRN hydrocodone-acetaminophen is to document administration in the MAR and then complete an assessment to make sure the medication was effective. The DON also stated there was no documentation that the medication was administered or followed up on for the two doses, and that the discrepancy between the controlled drug record and MAR potentially indicated diversion of a CS.
Failure to Monitor Anticoagulant Therapy for Adverse Effects
Penalty
Summary
The facility failed to ensure that Resident 5’s anticoagulant regimen was managed and monitored for adverse effects while the resident was receiving Eliquis (apixaban) 5 mg via gastrostomy tube twice daily for DVT prophylaxis. The resident’s face sheet listed diagnoses including atherosclerotic heart disease, long-term use of anticoagulants, and coronary angioplasty implant and graft. The resident’s H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills, moderately impaired vision, and total dependence for mobility and ADLs. The resident’s care plan for apixaban identified the resident as at risk for adverse effects from the medication and included an intervention to monitor for potential risk/effects and alert the physician when indicated. During record review and interview, the MDS-RN stated there was an order for Eliquis but no order could be found to monitor for adverse effects of its use. The MDS-RN also stated the care plan intervention was not followed to monitor for potential risk/adverse effect. During interview, the DON stated the resident’s use of Eliquis should have included a physician’s order, monitoring for adverse effects, and a care plan. The DON stated the physician should order the monitoring and it should be documented every shift, and acknowledged that the physician did not order the monitoring and licensed staff failed to communicate that there was no monitoring for adverse effects. The facility’s anticoagulation clinical protocol required assessment for signs and symptoms of adverse drug reactions and monitoring for complications such as excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, and the facility-provided Eliquis prescribing information stated the medication can cause bleeding that can be serious and rarely may lead to death.
Resident Charged for Lost Dentures
Penalty
Summary
The facility failed to ensure that one resident was not charged for the loss of dentures when the resident paid $800 for replacement of lost upper dentures. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and the H&P indicated the resident had capacity to understand and make medical decisions. The MDS indicated the resident could make self-understood and understand others, but needed assistance with oral and personal hygiene, toileting, bathing, and transfers. The resident’s concern record showed the full upper dentures were lost and the resident could not recall where they were left. The resident stated he filed a grievance after losing the upper denture and was frustrated that he had to pay $800 for replacement when it was not his fault. Social services confirmed the dentures were listed in the resident’s inventory and that the facility investigated the loss but could not locate them. Social services also stated the resident was told he had to pay $800 for timely availability of the denture and that the family was willing to cover the cost. The DON stated that because the denture was misplaced in the facility, the resident was not required to pay for it and reimbursement should have been facilitated, while the facility policy stated lost or damaged dentures would be replaced at the resident’s expense unless facility staff were responsible for the damage.
Infection Control Lapses With Medication Handling and Unlabeled Urinal
Penalty
Summary
The facility failed to maintain an infection prevention and control program when an LVN handled Resident 108’s fluticasone-salmeterol inhaler box in a manner that was not consistent with the facility’s infection control procedures. Resident 108 was admitted with diagnoses including COPD, acute respiratory failure with hypoxia, UTI, candidiasis, and a history of MRSA infection. During a medication administration observation, the LVN carried the labeled inhaler box into the resident’s shared room, placed it on the resident’s bedside rolling table without first cleaning the table, administered the medication, then returned the box to the medication cart drawer with other residents’ medications. During interview, the LVN stated the inhaler box should not have been placed on the resident’s table and then returned to the medication cart because it could result in cross contamination from the resident’s dirty table to the medication drawer and spread infection among residents. The DON stated the facility’s policy was not followed and that labeled inhaler boxes should not be taken into the resident’s room because they go directly in the medication cart next to other residents’ medications. The facility’s medication administration and infection control policies stated staff are to follow established infection control procedures and maintain a safe, sanitary, and comfortable environment to help prevent transmission of diseases and infections. The facility also failed to label Resident 103’s urinal with the resident’s name and the date it was provided. Resident 103 had diagnoses including UTI, urinary retention, history of falls, and depression, and required assistance with personal care and toileting. During observation, CNA 8 stated the urinal by the resident’s bed had no label and explained that urinals should be labeled with the resident’s name and date, especially in rooms with multiple residents, because they could be interchanged and lead to cross contamination. The DON stated urinals should be labeled to ensure proper identification and that an unlabeled urinal could inadvertently be used by another resident, leading to cross contamination and UTI. The facility’s policy for cleaning and disinfecting non-critical resident care items stated reusable items such as urinals are to be cleaned/disinfected between uses by a single resident.
Failure to Monitor Adverse Effects of IV Antibiotics
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents who were receiving IV antibiotics for serious infections. For one resident, the record showed diagnoses including UTI, sepsis, and bacteremia, and orders for Ampicillin sodium IV every 8 hours for sepsis for 10 days and Cefepime HCl IV every 8 hours for sepsis for 7 days. For the other resident, the record showed diagnoses including sepsis, local infection of the skin and subcutaneous tissue, and cellulitis of the left lower limb, with an order for Meropenem 1 gram IV every 8 hours for sepsis. For the resident receiving Ampicillin and Cefepime, the care plans included interventions to assess for signs and symptoms of complications and notify the MD/responsible party, but the licensed nurses’ notes showed one shift with missing adverse side effect monitoring. During interview, the MDS-RN stated antibiotics are significant medications and should be monitored for adverse effects every shift, and stated there was no physician order for monitoring adverse effects on the use of Ampicillin and Cefepime. The IP stated licensed nurses should monitor for adverse effects and document them in progress notes every shift, but he was not collecting adverse effect data and his antibiotic surveillance tracking form did not include adverse effects. The DON stated the nurses were responsible for ensuring the correct dose, indication, and monitoring of side effects/adverse effects, and stated the staff did not follow the facility’s antibiotic stewardship policies. For the resident receiving Meropenem, the baseline care plan indicated an intervention to monitor potential drug reactions daily, but the licensed nurses’ notes showed one shift with missing adverse side effect monitoring. During interview, the MDS-RN stated antibiotics should be monitored for adverse effects every shift and again stated there was no physician order for monitoring adverse effects on Meropenem. The IP stated licensed nurses should monitor for adverse effects and document them every shift, but adverse effects were not being collected on the antibiotic surveillance tracking form. The DON stated the failure to monitor adverse effects on Meropenem had the potential for the resident to suffer from adverse effects of the medication and antibiotic resistance, and stated the facility did not monitor adverse effects on the facility-provided prescribing information for Meropenem, Ampicillin, and Cefepime.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure appropriate use of a low air loss mattress (LALM) for a resident identified as being at risk for pressure ulcer (PU) development. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia, and essential hypertension, and had moderately impaired cognitive skills for daily decision making per the MDS. The resident’s care plan for pressure ulcers, last revised on 1/6/2026, identified a potential for PU development and included the use of pressure-relieving devices as needed. A physician’s order dated 3/17/2026 specified a LALM for skin care management. During an observation on 4/1/2026, the resident’s LALM was found with one fitted sheet, two layers of cloth chux, and a disposable brief between the resident and the mattress. An LVN stated that facility practice for LALM use required only one flat sheet and one chux or disposable brief, and explained that more than two layers of linen would prevent air circulation, create pressure, and trap moisture. A CNA reported that she had changed the resident’s disposable brief and placed two chux between the resident and the LALM before going on lunch break. The DON confirmed that LALM use in the facility required only one linen and one chux or disposable brief and acknowledged that multiple linen layers could prevent air circulation and cause friction. The facility’s Support Surface Guidelines policy indicated that redistributing support surfaces are used to prevent skin breakdown, promote circulation, and provide pressure relief or reduction, and to monitor for other PU risk factors and provide interventions as indicated.
Insulin Pen Labeled for Another Resident Brought to Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an LVN brought an insulin pen labeled for a different resident to the bedside. The affected resident had type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime. On the evening in question, the resident reported that an LVN entered the room around 11 p.m. with an insulin pen that had a male resident’s name on the label and placed it on the bedside tray table. The resident, who was oriented and knowledgeable about her medications, read the name on the pen, recognized it did not belong to her, and informed the LVN. The resident took a photo of the insulin pen, which showed a male first and last name corresponding to another resident. The resident stated that after pointing out the error, the LVN left the room with the incorrect pen and later returned with an insulin pen labeled with the correct name, after which the insulin injection was administered. The resident reported feeling stressed after discovering the medication error. In a subsequent interview, the LVN explained that while preparing medications at the cart outside the resident’s room, she removed an expired insulin pen that did not belong to the resident and placed it on top of the cart to address later. She then removed the correct resident’s insulin pen from the container and also placed it on the same side of the cart. While gathering the rest of the resident’s medications, she inadvertently picked up the other resident’s insulin pen from the top of the cart and brought it into the room, stating she had not yet read the name on the pen when the resident noticed the error. The DON and another LVN described the standard process for medication administration, including verifying the “five rights” and preparing medications for only one resident at a time, and facility policies required checking the medication label three times to ensure the right resident, medication, dose, time, and route. The incident occurred when these procedures were not followed, resulting in the wrong resident’s insulin pen being brought to the bedside and observed by the resident.
Failure to Document Insulin Medication Error Resulting in Incomplete Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and accurate medical record for one resident when a medication error was not documented in accordance with facility policy. The resident had a history of type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime. On the evening in question, the resident reported that an LVN entered the room around 11:00 p.m. with an insulin pen labeled with another resident’s name and placed it on the bedside tray table. The resident recognized that the insulin pen did not belong to her, informed the LVN, and took a photo of the pen showing a male resident’s first and last name. The LVN then left the room with the incorrect insulin pen and returned with the correct insulin pen labeled with the resident’s name, after which the resident received her insulin injection. The resident stated she felt stressed after discovering the medication error. In a subsequent interview, the LVN acknowledged that she had separated an expired insulin pen belonging to another resident from the medication cart container and placed it on top of the cart, then also placed the resident’s insulin pen on the same side of the cart while preparing medications. The LVN stated she mistakenly grabbed the other resident’s insulin pen from the top of the cart and brought it into the resident’s room, and that the resident identified the wrong name on the pen before administration. The LVN admitted she did not document this medication error and only reported it verbally to her RN supervisor. Review of the resident’s electronic medical record showed no nursing progress notes documenting a medication error or incident on that date. The DON and nursing staff stated that standard practice and facility policies require documentation of medication errors or incidents in the resident’s clinical record, including a factual description of the error and events, incidents, or accidents involving the resident. The failure to document the medication error resulted in an incomplete medical record for the resident on that date. Interviews with other nursing staff confirmed that insulin pens are labeled by pharmacy with resident names, that nurses are expected to verify the “five rights” (right patient, drug, dose, route, and time) when preparing and administering medications, and that medication errors must be documented in the clinical record. The facility’s policies on Charting and Documentation and on Adverse Consequences and Medication Errors require that events, incidents, or accidents involving the resident, and any medication errors, be documented in the resident’s medical record, including a factual description of the error. Despite these requirements, no documentation of the incident involving the wrong insulin pen was found in the resident’s record.
Failure to Timely Report Allegation of Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of visitor-to-resident verbal abuse within the required two-hour timeframe to the State Survey Agency, the ombudsman, and local law enforcement, as outlined in its own policies. A resident, who was cognitively intact and able to make decisions, reported that a visitor used inappropriate language towards her due to a complaint about a loud television. The incident was reported by the resident to a Social Service Assistant (SSA) the following morning, who then notified the Administrator (ADM) and attempted to address the issue with the visitor. Multiple staff interviews confirmed that the allegation of verbal abuse was recognized and discussed among staff, including the SSA, a Licensed Vocational Nurse (LVN), and a Registered Nurse (RN). Each staff member acknowledged that the use of inappropriate language constituted verbal abuse and that such allegations should be reported immediately to the appropriate authorities. However, there was a breakdown in communication between the SSA and the ADM, resulting in the ADM not being fully informed of the abuse allegation and, therefore, not initiating the required reporting and investigation procedures. The facility's policies clearly state that all allegations of abuse must be reported to the administrator and relevant authorities within two hours if abuse is involved. Despite this, the miscommunication led to a delay in reporting the incident, and the required notifications and investigation were not initiated in a timely manner. This failure resulted in a delay in the investigation and had the potential to place the resident at risk for abuse.
EHR Left Unattended, Compromising Resident Privacy
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of a resident's medical records when an electronic health record (EHR) was left open and unattended at a nurses' station. During an observation with the Director of Nursing (DON), it was noted that the EHR containing the resident's personal and medical information was accessible, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use to prevent unauthorized access, as leaving them open poses a risk of exposing protected health information. The resident involved had been admitted with diagnoses including hypertension, type 2 diabetes mellitus, and a history of falls. Assessment records indicated the resident was dependent on staff for several activities of daily living and was able to understand and communicate. Facility policy required that computer terminals be shielded from public view and that users log off or clear screens when leaving workstations unattended, which was not followed in this instance.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all surface-to-surface transfers and required the use of a mechanical lift with two-person assistance, was transferred without the use of the required mechanical lift. The resident had significant medical conditions, including hemiplegia affecting the right side, cerebral infarction, and end stage renal disease, and was assessed as a high fall risk. Facility records, including the Minimum Data Set and a facility-provided record, indicated that the resident's transfer protocol required a Hoyer lift and two-person assistance. On the day of the incident, the resident complained of new left leg pain and swelling, which was assessed by nursing staff. The resident reported to staff that a male staff member had transferred her without the Hoyer lift, and this was confirmed by interviews with the CNA and LVN involved. The resident's leg was found to be swollen, warm, and later developed significant bruising. Medical evaluation and imaging at a general acute care hospital revealed a left knee fracture involving the anterior tibial tuberosity and patellar tendon, with severe swelling and moderate effusion. Interviews with facility staff, including the CNA, LVN, RN, and Administrator, confirmed that the resident was transferred improperly, without the required mechanical lift and two-person assistance, which was not in accordance with the facility's policies and procedures. The improper transfer was identified as the cause of the resident's fracture, and the event resulted in the resident's transfer to the hospital for further evaluation and treatment.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, identified as Medication Cart 1 and Medication Cart 2, were left open and unattended in Nurses' Station 2. This observation was made during a concurrent interview with the Director of Nursing (DON), who confirmed that both carts were open and acknowledged that all medication carts should be locked when staff are out of sight. The DON stated that locking the carts is necessary for resident safety, as unlocked carts could allow unauthorized access to medications. A review of the facility's Policy and Procedures (P&P) titled 'Security of Medication Carts,' last reviewed on 9/27/2024, indicated that medication carts must be securely locked at all times when out of the nurse's view. The failure to lock the medication carts when unattended was identified as a deficient practice, as it had the potential to allow residents or unauthorized personnel access to the medications stored within the carts.
Failure to Accurately Document Resident Meal Intake in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for three residents were maintained in accordance with accepted professional standards and practice. Certified Nursing Assistants (CNAs) did not consistently document the percentage of food consumed by the residents at the correct times, resulting in incomplete and inaccurate nutritional intake records. For example, there were multiple instances where meal intakes were either not documented at all or were recorded at times that did not correspond with actual meal times, such as breakfast and lunch intakes being documented in the afternoon or evening. Resident 1, who had diagnoses including pneumonia, osteoarthritis, and dementia with severely impaired cognitive skills, had several days where meal intakes were missing or documented inaccurately. CNA 1 confirmed that the documentation was incomplete and not reflective of when meals were actually consumed. The Director of Staff Development also acknowledged that the documentation was incomplete and inaccurate, which could affect the identification of causes for weight changes. Similar issues were found for two other residents, both with significant cognitive impairments and medical conditions such as chronic kidney disease, hemiplegia, encephalopathy, and osteoarthritis. Their records also showed missing or inaccurately timed meal intake documentation. The Director of Nursing confirmed that CNAs should document meal intake after consumption and that records should not be left blank. The facility's own policy required that all services and changes in condition be documented objectively, completely, and accurately, but this standard was not met in these cases.
Failure to Set Low Air-Loss Mattress Correctly for Pressure Ulcer Prevention
Penalty
Summary
A resident with diagnoses including pneumonia, osteoarthritis, and dementia was admitted to the facility and assessed as being at moderate risk for pressure ulcer development, as indicated by a Braden Scale score of 14. The resident had severely impaired cognitive skills and required maximal assistance for mobility. Physician orders specified the use of a low air-loss mattress (LALM) for skin management. However, observations and interviews revealed that the LALM was set to 160 lbs, while the resident's actual weight was 115 lbs, as confirmed by both a CNA and LVN. The LALM setting was not adjusted according to the resident's weight, contrary to the manufacturer's guidelines and facility policy. Staff interviews confirmed that the LALM should have been set to 120 lbs based on the resident's weight, and that charge and treatment nurses were responsible for ensuring correct settings. The DON acknowledged that the incorrect LALM setting rendered the device ineffective in preventing pressure ulcers. Review of facility policy and the LALM operation manual further supported that mattress settings should be based on the resident's weight. This failure to ensure the LALM was set appropriately placed the resident at risk for the development of pressure ulcers.
Deficiency in Informed Consent for Psychotropic Medications
Penalty
Summary
The report identifies a deficiency in the facility's process of obtaining informed consent for the use of psychotropic medications for several residents. Resident 48 was admitted with diagnoses including major depressive disorder and congestive heart failure. Despite having the capacity to understand and make decisions, the informed consent forms for trazodone hydrochloride and temazepam were incomplete, lacking signatures from both the resident or their representative and the prescribing physician. This oversight was acknowledged by the RN and DON, who confirmed that the consent process was not followed, potentially leaving the resident unaware of the risks and benefits of the medications. Similarly, Resident 8, who was diagnosed with unspecified mood disorder and dementia, did not have completed informed consent forms for divalproex sodium and sertraline. The resident's capacity to understand and make decisions was impaired, necessitating consent from a representative. However, the forms were blank, and the medications were administered without documented consent. The MDS Nurse and DON both recognized the failure to obtain informed consent, which could result in the administration of psychotropic medications without the family's knowledge or agreement. The report also highlights deficiencies in the informed consent process for Residents 96 and 89. Resident 96, with diagnoses of anxiety disorder and major depressive disorder, had incomplete informed consent forms for sertraline and alprazolam, lacking documentation of who consented to the medication use. Resident 89, diagnosed with major depressive disorder and dementia, did not have a new informed consent obtained when the dosage of quetiapine was increased. The DON confirmed that the facility's policy was not followed, denying residents their rights to informed care and potentially leading to the use of unnecessary psychotropic drugs.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to promote resident rights by not making the most recent survey results easily accessible to residents, family members, and legal representatives. During an interview with seven resident council group attendees, it was revealed that they were unaware of where to find the survey results. They pointed to a black metal rack outside the Activity Director's office, but upon inspection, no survey binder was found there. The Activity Director later indicated that the binder was placed on a table outside the social services and admissions office, but it was not visible as it was placed underneath the tabletop without a sign. Additionally, the binder did not contain the most recent recertification survey results from 2024. The Administrator acknowledged that the State inspection results should be available for all residents and their representatives to understand what the facility is working on. The facility's policy and procedure on Resident Rights, last reviewed in September 2024, stated that a copy of the most recent standard survey should be maintained in a three-ring binder in an area frequented by most residents, such as the main lobby or resident activity room. However, the facility did not adhere to this policy, resulting in residents and their representatives not having access to examine the most recent survey results.
Failure to Follow Restraint Protocols for Residents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the cases of two residents. Resident 49 had a bed alarm applied without a restraint assessment, physician's order, informed consent, or a care plan. The bed alarm was used because Resident 49 was at high risk for falls, but the necessary procedures to justify its use as a restraint were not followed. This oversight placed Resident 49 at risk for restriction of movement, which could lead to a decline in physical function. Resident 267 was found with pillows tucked under the fitted sheet on both sides of the bed, which restricted the resident's movement. This was done as a safety measure due to the resident's history of falls and attempts to dangle legs over the bed. However, there was no restraint assessment, physician's order, informed consent, or care plan in place for this intervention. The use of pillows in this manner was acknowledged by staff as a form of restraint, yet the proper protocols were not followed, potentially leading to a decline in the resident's functioning. The facility's policy on the use of restraints requires a thorough assessment, physician's order, informed consent, and a care plan before implementing any restraint. These steps were not taken for either resident, indicating a failure to adhere to the facility's own policies and procedures. The Director of Nursing confirmed that the use of pillows as a restraint was not acceptable and that the necessary steps were not taken to ensure the safety and well-being of the residents involved.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The facility failed to implement the care plans for two residents, leading to deficiencies in monitoring for adverse effects of medications. Resident 42, who was prescribed Eliquis and clopidogrel for atrial fibrillation, did not receive monitoring for signs and symptoms of bleeding and bruising, as outlined in their care plan. Additionally, Resident 42 was prescribed gabapentin for epilepsy, but there was no documentation of monitoring for drug toxicity, which was also required by the care plan. Resident 79, diagnosed with hyperlipidemia and prescribed atorvastatin, did not have a lipid panel conducted to monitor the effectiveness of the medication. The care plan for Resident 79 required monitoring of lipid levels to assess the risk of cardiac distress and the effectiveness of atorvastatin, but no such monitoring was documented. The Director of Nursing acknowledged the lack of documentation and monitoring for both residents, which was considered a standard of practice. The Consultant Pharmacist also failed to identify these deficiencies in their monthly drug regimen reviews. The facility's policies and procedures emphasized the importance of monitoring for adverse drug reactions and maintaining the highest level of resident functionality, which were not adhered to in these cases.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating subcutaneous insulin administration sites for three residents, leading to a deficiency in care. Resident 17, who was readmitted with diagnoses including type 2 diabetes mellitus and dementia, had physician's orders for insulin administration that required site rotation. However, the Medication Administration Record (MAR) indicated that the insulin was repeatedly administered in the same area, contrary to the physician's orders and the manufacturer's guidelines. This oversight was acknowledged by RN 1 and the Director of Nursing (DON), who both confirmed the necessity of site rotation to prevent adverse effects such as pain and skin complications. Similarly, Resident 48, who had intact cognition and required assistance with activities of daily living, also received insulin injections without proper site rotation. The MAR showed repeated administration in the same abdominal areas, despite clear physician's orders to rotate sites. RN 1 and the DON reiterated the importance of following the guidelines to prevent skin issues and other complications associated with improper insulin administration. Resident 107, admitted with type 2 diabetes mellitus and other health conditions, also experienced the same deficiency. The Location of Administration Report revealed multiple instances where insulin was administered in the same site, contrary to the facility's policy and the manufacturer's guidelines. The DON confirmed that the licensed nurses should have rotated the injection sites to prevent potential adverse effects. This consistent failure to rotate injection sites for insulin administration across multiple residents highlights a significant lapse in adhering to professional standards of care.
Failure to Maintain a Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to multiple deficiencies. Resident 4, who was at high risk for falls due to dementia and other conditions, had floor mats intended to prevent injury from falls. However, observations revealed that a wheelchair and an overbed table were placed on top of these mats, compromising their effectiveness. Staff interviews confirmed that placing items on the mats was against policy and could lead to injury if the resident fell. Similarly, Resident 272, also at high risk for falls, had floor mats improperly placed with equipment on top of them, and a bed alarm was not installed as ordered. Observations and staff interviews highlighted that these practices could affect the integrity of the mats and increase the risk of injury during falls. The facility's policies emphasized the importance of keeping the environment free from obstacles and ensuring interventions were properly implemented, which was not adhered to in these cases. Additionally, Resident 70's room had environmental hazards, including a broken baseboard with protruding nails and a damaged windowsill, which were not addressed promptly. The Maintenance Director admitted to leaving the hazards unattended for a week, and the DON acknowledged the potential for injury. Furthermore, Resident 13 was left unattended in a high bed position during wound care, contrary to safety protocols, increasing the risk of falls. These deficiencies demonstrate a failure to maintain a safe environment and adhere to established safety policies.
Deficiencies in Oxygen Therapy Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of oxygen therapy for residents requiring respiratory care. Resident 70, who was readmitted with diagnoses including metabolic encephalopathy, sepsis, and dementia, was observed receiving oxygen therapy via nasal cannula. However, there was a lack of documentation on the Medication Administration Record (MAR) for the administration of PRN oxygen, despite the resident's oxygen saturation levels being recorded. Interviews with nursing staff revealed inconsistencies in the documentation process, with some staff acknowledging the importance of documenting oxygen administration but failing to do so consistently. Similarly, Resident 74, diagnosed with Alzheimer's Disease and other conditions, was observed receiving oxygen therapy without proper documentation in the MAR. The resident had a physician's order for PRN oxygen, but the administration was not consistently recorded, and there was no evidence of monitoring for the effectiveness of the oxygen therapy. Staff interviews indicated a lack of adherence to the facility's policy on documenting PRN oxygen use, which could lead to unnecessary administration and failure to address underlying causes of respiratory distress. Additionally, the facility failed to maintain proper infection control practices for Resident 96, whose oxygen tubing was observed touching the floor. This practice poses a risk of respiratory infections due to potential contamination. The facility's policy requires immediate replacement of contaminated tubing, but this was not adhered to, as confirmed by staff interviews. These deficiencies in respiratory care and infection control practices have the potential to place residents at risk for respiratory distress and infections.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received treatment consistent with professional standards of practice. The deficiency involved a lack of documented assessments by licensed nurses after the resident's HD sessions. This failure was identified for one resident who was dependent on HD due to end-stage renal disease and hypertension. The resident was admitted to the facility with these diagnoses and had a care plan in place to document the condition post-HD. The facility's policy required licensed nurses to perform and document post-HD assessments immediately upon the resident's return from the dialysis center. These assessments were crucial to detect any changes in the resident's condition, such as changes in consciousness, bleeding from the arteriovenous shunt, or changes in vital signs. However, the review of the resident's Dialysis Communication Record forms revealed multiple instances where these assessments were not documented, indicating they may not have been performed. Interviews with the Minimum Data Set Nurse and the Director of Nursing confirmed the importance of these assessments and the facility's policy requirements. Despite monthly in-services on completing the Dialysis Communication Record, the documentation was incomplete, suggesting non-compliance with the facility's policy. The lack of documentation for post-HD assessments placed the resident at risk for delayed care and detection of potential complications from HD.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to account for three doses of controlled medications for three residents, leading to a deficiency in pharmaceutical services. During an observation and interview, it was found that there was a discrepancy between the controlled drug record accountability log and the actual medication count in the medication cart. Specifically, one dose of Belbuca for Resident 5, one dose of hydrocodone with acetaminophen for Resident 97, and one dose of pregabalin for Resident 272 were missing from the medication cart or bubble pack compared to the accountability log. Licensed Vocational Nurse (LVN) 3 admitted to administering the medications to the residents but failed to document the administration on the accountability logs as per the facility's policy and procedures. This failure to document immediately after administration led to a lack of control and accountability for the controlled medications, increasing the risk of medication errors and potential harm to the residents. The Director of Nursing confirmed that LVN 3 did not follow the facility's policy of documenting the preparation and administration of controlled medications immediately. The residents involved had specific medical conditions requiring these medications. Resident 5 was prescribed Belbuca for chronic pain, Resident 97 was prescribed hydrocodone with acetaminophen for pain management related to pressure ulcers and disc degeneration, and Resident 272 was prescribed pregabalin for neuropathy. The failure to document the administration of these medications accurately could lead to medication errors and potential harm to the residents, as noted by LVN 3 and the Director of Nursing.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The Consultant Pharmacist (CP) failed to report irregularities in the monthly drug regimen review for two residents, leading to deficiencies in monitoring for potential adverse effects of medications. Resident 42, who was prescribed Eliquis and clopidogrel for atrial fibrillation, was not monitored for signs and symptoms of bleeding and bruising, which are critical due to the blood-thinning nature of these medications. Additionally, Resident 42 was prescribed gabapentin for epilepsy but was not monitored for signs of drug toxicity, such as nausea, dizziness, or chest pain, as outlined in the resident's care plan. Resident 79, diagnosed with hyperlipidemia and prescribed atorvastatin, was not monitored for lipid levels through a lipid panel, which is essential to assess the effectiveness of the medication and adjust the treatment plan if necessary. The facility's policies and procedures require such monitoring to prevent adverse consequences and ensure the medications are providing the intended benefits without causing harm. The Director of Nursing (DON) acknowledged the lack of documentation and monitoring for both residents, which was supposed to be recorded in the Medication Administration Record (MAR). The CP admitted to failing to identify these monitoring deficiencies in the drug regimen reviews conducted over several months. The facility's policies emphasize the importance of monitoring for adverse drug reactions and maintaining the highest practicable level of functioning for residents, which was not adhered to in these cases.
Failure to Monitor Drug Regimens and Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary drugs by not adequately monitoring for side effects and adverse consequences. Resident 42 was prescribed Eliquis and clopidogrel for atrial fibrillation and gabapentin for epilepsy. However, there was no documentation of monitoring for signs and symptoms of bleeding and bruising associated with the use of Eliquis and clopidogrel, nor was there monitoring for signs of drug toxicity related to gabapentin. This lack of monitoring was noted in the resident's Medication Administration Record (MAR) for March 2025, despite the care plan indicating the need for such monitoring. Resident 79, who was prescribed atorvastatin for hyperlipidemia, did not have a lipid panel ordered or conducted since admission to the facility. The care plan for Resident 79 indicated the need to monitor the effect of the medication and perform laboratory work, but the clinical chart lacked any lipid laboratory results. This oversight was confirmed during an interview with a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the importance of monitoring lipid levels to ensure the effectiveness of atorvastatin. Resident 40, who was on apixaban for deep vein thrombosis prophylaxis, did not have an order for monitoring adverse effects of the medication. The care plan highlighted the risk of adverse effects from this high-risk drug class, yet there was no monitoring for potential bleeding. The Director of Nursing confirmed that staff should have obtained an order for monitoring adverse effects and emphasized the importance of such monitoring to prevent complications. The facility's policies and procedures also underscored the need for monitoring adverse drug reactions and ensuring residents maintain the highest practicable level of functioning.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for five residents were free from unnecessary psychotropic medications. Resident 95 was admitted with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder. The resident was prescribed lorazepam PRN for restlessness or shortness of breath, but the order was not transcribed correctly, lacked an end date, and was administered beyond the 30-day limit without proper evaluation or documentation. This oversight placed the resident at risk of receiving unnecessary medication without a documented rationale for its continued use. Resident 79 was prescribed mirtazapine and divalproex for mood disorders, but there was no specific, measurable target behavior documented for their use. Despite the absence of depressive symptoms or poor appetite, there was no attempt for a Gradual Dose Reduction (GDR) or documented clinical rationale for continuing the medications. Similarly, Resident 89 was prescribed fluoxetine for depression without a specific behavior to monitor, leading to potential unnecessary use of the medication. The lack of specific behavior monitoring could result in inaccurate assessments of the medication's effectiveness. Resident 8 was administered sertraline and divalproex sodium without documented informed consent from the resident's representative. The orders lacked specific behaviors to monitor, which could lead to inaccurate monitoring and unnecessary medication administration. Resident 63 was prescribed alprazolam PRN for anxiety before dental procedures without a stop date, increasing the risk of unnecessary medication use. The facility's failure to adhere to its policies on psychotropic medication use and informed consent contributed to these deficiencies.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.5% error rate during a survey. This deficiency affected two residents, who experienced medication administration errors. Resident 21 received carvedilol at a different time than prescribed, was given an incorrect form of multivitamin, and did not receive polyethylene glycol as ordered. Resident 77 also received carvedilol at a time different from the physician's order. The errors were observed during medication administration rounds. LVN 1 administered carvedilol to Resident 77 at 9:15 a.m., outside the prescribed time frame of 7:15 a.m. with breakfast. LVN 3 administered carvedilol and an incorrect multivitamin to Resident 21 at 9:27 a.m., instead of the scheduled 7:15 a.m. with breakfast, and failed to administer polyethylene glycol. Both LVNs cited being busy with other residents as the reason for the delays and errors. Interviews with the LVNs and the Director of Nursing confirmed these errors and acknowledged the potential for adverse effects due to the deviations from prescribed medication schedules. The facility's policies require medications to be administered within a 60-minute window of the prescribed time, which was not adhered to in these instances. The facility's policy also emphasizes the importance of following physician orders to prevent medication errors and adverse consequences.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Three residents, identified as Residents 107, 17, and 48, were affected by this deficiency. The primary issue was the failure to rotate subcutaneous insulin administration sites as per physician's orders, manufacturer's guidelines, and accepted professional standards. This oversight was identified during a review of the residents' medication administration records and confirmed through interviews with nursing staff and the Director of Nursing (DON). Resident 17, who was readmitted to the facility with diagnoses including type 2 diabetes mellitus and dementia, had physician's orders for insulin lispro that required site rotation. However, the medication administration records indicated that the insulin was repeatedly administered in the same area, contrary to the physician's orders and facility policy. Similarly, Resident 48, with diagnoses of type 2 diabetes mellitus and congestive heart failure, also had orders for insulin administration that were not followed correctly, as the injection sites were not rotated as required. Resident 107, admitted with type 2 diabetes mellitus and chronic kidney disease, also experienced the same issue with insulin administration. The records showed multiple instances where the insulin was administered in the same site without rotation. Interviews with the nursing staff and the DON confirmed that the failure to rotate injection sites was a medication error, as it did not comply with the physician's orders, manufacturer's guidelines, or professional standards. This deficiency had the potential to cause adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis.
Failure to Update Staffing Plan Leads to Medication Delays
Penalty
Summary
The facility failed to revise and provide a current staffing plan in the Facility's Assessment, which evaluates the resident population and determines the necessary resources to care for residents competently during both day-to-day operations and emergencies. This deficiency resulted in residents receiving medications later than scheduled, specifically affecting Residents 21 and 77, who received their carvedilol doses after the prescribed time. The delay in medication administration was acknowledged as a medication error by the Licensed Vocational Nurses (LVNs) involved. Interviews with LVNs revealed that the delay in administering medications was due to the high number of residents assigned to each nurse, which exceeded the facility's assessed staffing ratio of 1 LVN to 24 residents. LVNs reported being unable to administer medications within the required timeframe due to being occupied with other tasks such as handoffs, resident rounds, and medication cart checks. The facility's policy allowed a 60-minute window for medication administration, but the LVNs were unable to meet this requirement due to their workload. The facility's assessment, dated 12/1/2024, indicated a staffing need of 1 LVN per 24 residents during the day shift. However, the actual staffing ratios between 3/11/2025 and 3/13/2025 were significantly higher, with LVNs being assigned to 36 to 45 residents each. The Administrator acknowledged that a new assessment was needed when the facility's acuity changed, but no new assessment had been conducted since 12/1/2024. The failure to maintain the assessed staffing ratio contributed to the delay in medication administration and the resulting medication errors.
Inadequate Linen Cart Covers Compromise Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that clean linens were adequately protected from environmental contaminants. During observations and interviews, it was found that all 17 clean linen carts were covered with a permeable, loosely woven material, which allowed air and water to pass through. This material was not suitable for preventing contamination from dust and liquids, as confirmed by the Infection Preventionist and the Housekeeping Supervisor. The Director of Nursing acknowledged that the linen cart covers had not been changed since the last recertification survey and recognized the importance of using non-porous covers to maintain linen cleanliness. The facility's current practice involved using bleach wipes for cleaning the linen carts, which were only recommended for hard, non-porous surfaces, according to the Safety Data Sheet. The Manufacturer's Guidelines for the linen cart covers also indicated that the material was not suitable for the facility's cleaning methods. The facility's policy on cleaning and disinfection required adherence to CDC and OSHA standards, which were not met due to the use of porous linen cart covers. This deficiency had the potential to spread infections and illnesses among residents and staff.
Failure to Honor DNR Order for a Resident
Penalty
Summary
The facility failed to honor the Do Not Resuscitate (DNR) order for Resident 115, which resulted in a violation of the resident's rights to dignity and respect. Resident 115, who had been diagnosed with metabolic encephalopathy, sepsis, and dementia, was found unresponsive with no vital signs. Despite having a DNR order in place, facility staff initiated cardiopulmonary resuscitation (CPR) and called emergency services, who continued resuscitation efforts until the resident was pronounced deceased. The deficiency occurred because the Preferred Intensity of Care (PIC) Authorization/Decisions form, which indicated the resident's DNR status, was not properly filed in the resident's current chart upon readmission. The MDS Nurse and Social Services Director acknowledged that the form was mistakenly filed in the resident's old chart, leading to the assumption that the resident was full code status. This oversight meant that the resident's wishes were not followed, and CPR was administered contrary to the DNR order. Interviews with facility staff, including the MDS Nurse, Social Services Director, and Director of Nursing, revealed a lack of adherence to the facility's policies and procedures regarding DNR orders. The staff admitted that the resident's preferred intensity of care should have been verified and documented in the current chart upon readmission. The facility's policies clearly state that DNR orders must be followed unless a signed request to end the order is provided, which was not the case for Resident 115.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident 46, who was admitted with multiple diagnoses including dementia and a history of falls, was observed with the call light hanging on the wall, out of reach. The resident's care plan specifically indicated that the call light should be within easy reach to encourage its use for assistance. During an observation, the Infection Preventionist acknowledged the oversight and confirmed that the call light should have been placed within reach for dignity reasons and to allow the resident to call for help if needed. Similarly, Resident 107, who was alert and oriented, was found with the call light resting on the floor beside the bed. The Assistant Director of Staff Development and a Registered Nurse both confirmed that the call light should always be within reach to allow the resident to call for help when necessary. The Registered Nurse also noted that if the call light frequently falls, it should be clipped to the bed sheet to prevent it from becoming a trip hazard and to ensure it remains accessible. The Director of Nursing reviewed the facility's policies and procedures, which emphasized the importance of having the call light accessible to residents to ensure timely responses to their needs. The failure to adhere to these policies resulted in a deficiency, as the call lights were not within reach for the residents, potentially delaying care and services.
Failure to Assist with Advance Directives for Two Residents
Penalty
Summary
The facility failed to offer assistance with formulating an Advance Directive (AD) to two residents, Residents 79 and 97, upon their admission. Resident 79 was originally admitted on January 29, 2024, and readmitted on September 17, 2024, with diagnoses including dementia and hemiplegia following a stroke. The resident's records indicated severely impaired cognition and a need for substantial assistance with daily activities. Despite these conditions, the facility did not document any inquiry or assistance offered to the resident's representative regarding the presence or formulation of an AD. Similarly, Resident 97, admitted on June 26, 2024, with Alzheimer's Disease and other mental health conditions, also had severely impaired cognition and required maximal assistance with daily activities. The facility's records for Resident 97 also lacked documentation of any inquiry or assistance offered to the resident's representative about an AD. Interviews with the Social Services Director and a Registered Nurse confirmed that the necessary steps to inquire about or assist with ADs were not taken for either resident. The facility's policy on Advance Directives, last reviewed on September 27, 2024, mandates that the social services director or designee inquire about the existence of any written ADs upon admission. The policy also requires that information about ADs be prominently displayed in the medical record. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and inquiry regarding ADs for both residents, potentially impacting their care in emergencies.
Deficiencies in Providing a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, leading to deficiencies in their living conditions. Resident 79, who has severe cognitive impairment and is at high risk for falls, was found to have a floor mat with tears covered by black tape and one tear that was not covered. Despite the presence of a physician's order for bilateral floor mats to prevent injury, the staff did not notify the maintenance department to replace the damaged mat, compromising the resident's safety and the homelike environment. Resident 70, who is dependent on staff for daily activities and has limited cognitive abilities, was found in a room with a broken baseboard and windowsill, exposing nails and broken concrete. The Maintenance Director had left the room in this condition for about a week, believing it was not unsafe. Additionally, red stenciled letters were observed on the wall, which were unrelated to the resident and contributed to an institutional rather than homelike setting. The Director of Nursing acknowledged that these conditions were hazardous and not in line with the facility's policy for a homelike environment. The facility's policy on providing a homelike environment emphasizes safety, cleanliness, and personalization, which were not upheld in these cases. The deficiencies observed in the residents' rooms had the potential to negatively impact their psychosocial well-being and comfort, as the facility failed to maintain a clean and orderly environment as required by their policy.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy and return form to a resident's representative when the resident was transferred to a general acute care hospital. This deficiency was identified during a review of the records for a resident who was admitted to the facility with diagnoses including metabolic encephalopathy, sepsis, and pneumonitis. The resident was transferred to the hospital due to coffee ground emesis, hypotension, and tachycardia, with a seven-day bed hold indicated in the order summary report. However, the facility did not provide the required written notification of the bed-hold policy to the resident or their representative at the time of transfer. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the notification was not provided. The facility's policy requires that residents and their representatives be informed in writing of the bed-hold policy both in advance of any transfer and at the time of transfer, or within 24 hours in the case of an emergency. The failure to provide this notification could result in the resident's responsible party being unaware of the bed-hold policy, potentially leading to the resident being transferred to another skilled nursing facility not of their preference.
Failure to Adhere to DNR Order for Resident
Penalty
Summary
The facility failed to adhere to a Do Not Resuscitate (DNR) order for a resident, identified as Resident 115, who was administered cardiopulmonary resuscitation (CPR) despite having a documented DNR order. The resident had been admitted with conditions including metabolic encephalopathy, sepsis, and dementia, and was not capable of making decisions regarding their care. The resident's representative had authorized no CPR, consistent with the resident's wishes, as documented in the Preferred Intensity of Care (PIC) Authorization/Decisions form. The deficiency occurred when Resident 115 was found unresponsive with no vital signs, and CPR was initiated by facility staff. The PIC Authorization/Decisions form, which indicated the resident's DNR status, was not filed in the current chart upon the resident's readmission, leading staff to consider the resident as full code status. The Social Services Director acknowledged the oversight in not verifying the resident's previous PIC Authorization/Decisions form, which resulted in the administration of CPR contrary to the resident's documented wishes. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the facility's policy and procedure for handling DNR orders were not followed. The facility's policy required that DNR orders be respected unless a signed request to end the DNR order was provided by the resident or their legal surrogate. The failure to properly document and communicate the resident's DNR status led to the violation of the resident's rights and preferred treatment wishes.
Failure to Conduct Change of Condition Assessment
Penalty
Summary
The facility failed to ensure a comprehensive assessment for a resident who experienced a significant change of status. The resident, who had been admitted with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, and the presence of vascular implants and grafts, was discharged to a General Acute Care Hospital due to abnormal laboratory results indicating elevated white blood cells and blood urea nitrogen levels. Despite these significant changes, no change of condition assessment was performed on the day of the transfer, as confirmed by the review of records and interviews with facility staff. The lack of a change of condition report was acknowledged by both a Registered Nurse and the Director of Nursing during interviews. The facility's policy requires that such assessments be conducted to document and communicate the resident's condition and the interventions provided prior to transfer. This omission in documentation and communication had the potential to negatively affect the provision of necessary care and services to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,033 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sherman Oaks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherman Oaks Hospital Snf Dp | 0 mi | ★★★★★ | 12 | 0 |
| Sherman Village Hcc | 2.3 mi | ★★★★★ | 17 | 0 |
| Encino Hospital Medical Center D/p Snf | 2.3 mi | ★★★★★ | 7 | 0 |
| Berkley Post-acute | 2.4 mi | ★★★★★ | 8 | 0 |
| The Care Center On Hazeltine, Llc | 2.5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sherman Oaks Health & Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.