Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Hospital Snf Dp during CMS and state inspections, most recent first.
A facility exceeded the 5% medication error threshold after an RN gave pantoprazole and sucralfate through GTs while tube feedings were infusing. One resident had gastric and duodenal ulcers with GI bleed history, and another resident was comatose and on mechanical ventilation. Staff interviews and record review showed pantoprazole should be given before a meal and sucralfate on an empty stomach, but both were administered during continuous enteral feeding.
A resident on a puree diet was served rice pilaf, cod, and carrots that were thin and watery, with the foods merging together on the plate instead of holding a pudding-like consistency. The FSD said the texture was not appropriate, and the DON stated puree foods should be applesauce-like and hold their shape. The resident had a hx of stroke and traumatic brain dysfunction and was dependent on staff for eating.
Failure to document and implement a physician order for two-hour repositioning and skin care. A resident with respiratory failure, TBI, persistent vegetative state, and seizure disorder had orders for turning and routine skin care every two hours, along with care plan interventions to check for wetness and soiling every two hours. RN stated there was no documentation of wetness checks every two hours, and the DON stated the facility documented repositioning once per shift instead of as ordered.
Failure to Provide Individualized Activities: A resident with a hx of stroke and traumatic brain dysfunction, whose cognition was intact and who was dependent on staff for several ADLs, stated he wanted more books and hands-on activities while observed watching TV. The AD said he liked using an iPad but was not allowed to use it at that time, and only two children's books were available. The AD also reported a scheduled aromatherapy activity was unavailable because the facility ran out, and no replacement activity had been arranged.
A resident with respiratory failure, TBI, persistent vegetative state, and a seizure disorder had an 8.23% weight loss documented on the weight record, but there was no documentation that the significant loss was reported to the MD. The care plan required staff to monitor weight and report significant loss or gain, while RN stated there was no documentation addressing the weight loss or the reason for the reweighing, and the DON stated physician notification was important to obtain new orders and interventions.
A resident with severe cognitive impairment and a feeding tube had ongoing weight loss documented on nutrition assessments, and the RD recommended monitoring blood glucose and HgbA1C due to a history of DM. Nurses’ notes contained no documentation that the RD’s HgbA1C recommendation was followed through, and the last HgbA1C on record was from 2024. The facility policy required RD recommendations for lab levels and other nutrition-related changes to be followed and documented within one week.
Failure to Maintain Required HOB Elevation During Tube Feeding: A resident who was comatose, mechanically ventilated, and receiving enteral nutrition had a physician order and care plan directing HOB elevation to 35 to 45 degrees during feeding. During observation, the resident was lying on the right side with tube feeding infusing while the HOB was only 25 degrees. RN confirmed the position was below the ordered level, stated it should have been higher to prevent aspiration, and the DON stated staff should follow the physician's order.
Nursing staff failed to follow physician orders and facility policy for flushing g-tubes with water before, after, and between medication administrations for three residents with severe cognitive impairment and feeding tubes. In each case, staff either did not flush with the required amount of water or omitted flushing between medications, as observed and confirmed by interviews and record reviews.
The facility failed to ensure its medication error rate remained below 5%, with four errors out of 26 observed opportunities. Two residents with g-tubes did not have their tubes flushed with water between medication administrations, as required by physician orders and facility policy. Nurses acknowledged missing the required flushes, and the Director of Subacute confirmed these were medication errors.
Surveyors found that kitchen staff failed to label opened boxes of bacon, sausage, and a tray of eggs with open or use by dates, as required by facility policy. This lapse in food storage practices had the potential to affect a medically compromised resident who received food from the kitchen.
Two residents who were dependent on staff for all activities of daily living and had significant medical conditions were found with their call lights out of reach, despite care plans and facility policy requiring call lights to be accessible at all times. Staff confirmed during observations and interviews that the call lights should have been placed within reach, but this was not done after providing care.
A resident with chronic respiratory failure, seizure disorder, and a tracheostomy experienced a significant change in condition, including fever and increased secretions. Nursing staff observed these symptoms late at night but did not notify the attending physician until approximately six hours later, resulting in a delay in obtaining new medical orders. Staff interviews and record review confirmed that this delay was not in accordance with facility policy for timely physician notification.
A resident with a history of deep tissue injury and significant cognitive and physical impairments was observed with heels resting on the mattress, despite physician orders and a care plan requiring heels to be floated on two pillows. A nurse confirmed the intervention was not followed, in violation of facility policy for pressure ulcer management.
A resident with chronic respiratory failure, encephalopathy, and dementia, who was fully dependent on staff, was observed lying in bed with the bed brakes unlocked and no staff present. A nurse confirmed this was unsafe, and the bed's manual requires brakes to be applied whenever a resident is in bed.
A resident with significant medical needs and an indwelling urinary catheter was observed with catheter tubing that was looped and not draining properly, despite care plan and facility policy requirements to keep tubing free of kinks and obstructions. A nurse confirmed the improper positioning, which could impede urine flow and increase infection risk.
A resident receiving TPN via a PICC line did not have the TPN bag and tubing labeled with the date and time they were started, as required by facility policy. This lapse was confirmed by an RN during observation, despite the resident's care plan specifying adherence to protocol for tubing changes. The resident had significant medical needs and was fully dependent on staff.
A resident who was ventilator-dependent and required frequent suctioning had a Yankauer suction catheter in use that was not labeled with the date it was to be changed next, as required by facility policy. Staff interviews confirmed that all respiratory equipment should be labeled after being changed, but the catheter in the resident's room lacked this information, making it unclear when it was last replaced and placing the resident at risk for infection.
Two residents experienced inaccurate medical record documentation: one received a different form of docusate sodium than what was ordered, and another was administered Eliquis despite documentation of bleeding. Staff failed to clarify orders and document care accurately, resulting in discrepancies between physician orders and actual care provided.
The facility did not follow its antibiotic stewardship policy for two residents by failing to monitor and document antibiotic use, side effects, and adverse reactions, and by not completing the infection control surveillance log for antibiotic therapy. Staff interviews confirmed that required monitoring and documentation were not performed, and key information was missing from surveillance records.
The facility failed to ensure its Infection Preventionist was qualified and competent in managing the infection control program, as evidenced by a lack of monitoring for antibiotic use and adverse reactions in a resident, and incomplete documentation in the Infection Control Surveillance Log for another resident receiving antibiotics. The IP had not established required surveillance processes and had not fulfilled job description requirements.
The facility failed to establish and implement a policy on enhanced barrier precautions (EBP) to reduce the transmission of multidrug-resistant organisms (MDROs) in four residents. Staff did not follow EBP protocols, such as wearing gowns during high-contact care activities, despite the residents' high risk of infection. The Nurse Manager, Infection Preventionist, and Chief Nursing Officer acknowledged the lack of EBP implementation and staff training.
The facility failed to rotate subcutaneous injection sites for three residents receiving heparin, enoxaparin sodium (Lovenox), and Lantus insulin, leading to potential risks of bruising and bleeding. This was confirmed by the MDSC-RN, PHARM 1, and the NM, and was against the facility's policy and prescribing information for these medications.
The facility failed to act on pharmacist recommendations for three residents, including not tapering methadone dosage, not documenting conditions for lorazepam administration, and not discontinuing Robitussin when not in use.
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous injection sites for three residents receiving heparin, enoxaparin sodium (Lovenox), and Lantus insulin. This failure was confirmed by the MDSC-RN, pharmacist, and NM, and was identified as a significant medication error by the surveyors.
The facility failed to adhere to food safety standards by not storing the ice scooper in a covered container, not ensuring a food service worker wore a hairnet, and not labeling an opened container of canola/extra virgin olive oil with an open date. These practices could lead to foodborne illnesses among residents.
The facility failed to maintain an infection prevention and control program, including not sanitizing a barcode scanner between uses, not implementing Enhanced Barrier Precautions during medication administration for residents with indwelling devices, and not discarding single-use normal saline vials after use.
The facility failed to develop and implement comprehensive care plans on enhanced barrier precaution isolation for two residents, leading to potential infection control issues. Both residents lacked appropriate signage and isolation carts, and the LVN did not wear a gown during medication administration. The facility did not adhere to its care planning policies, risking the spread of infection.
The facility failed to ensure adequate supervision by leaving a medication cup with ointments unattended in a shared room, involving two residents who were totally dependent on staff. This breach of policy posed a risk of accidental ingestion.
The facility failed to properly administer and document IV fluids for two residents. One resident's midline catheter dressing was not labeled with the date of the last change, and another resident's midline catheter care and dressing changes were not documented as required. These deficiencies were against the facility's policies and placed the residents at risk for complications.
The facility failed to ensure proper medication storage and labeling when an opened and unlabeled single-use vitamin A&D ointment packet was found in Medication Cart 2. The LVN and Nurse Manager confirmed that the ointment should have been discarded or labeled, indicating a lapse in following the facility's policies.
A facility failed to inspect a handheld nebulizer compressor by its due date, compromising a resident's respiratory care. The resident, in a persistent vegetative state, required routine and as-needed nebulizer treatments. Staff interviews revealed confusion over inspection responsibilities, and the Biomed Engineering Site Lead confirmed the nebulizer was out of service due to missed inspections.
Medication Administration Errors With Tube Feedings
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent, with 2 errors observed in 26 opportunities for a 7.69 percent error rate. During the medication administration task, RN 2 administered pantoprazole to one resident through a gastrostomy tube while continuous tube feeding was infusing, rather than giving it 30 minutes before a meal. The resident had a history of gastric and duodenal ulcers, acute blood loss anemia secondary to GI bleed, and was receiving tube feeding and ventilator support. The same nurse also administered sucralfate to another resident through a gastrostomy tube while tube feeding was infusing during the routine noon medication pass. That resident was comatose, on mechanical ventilation, and receiving tube feeding. The order for sucralfate was for every 6 hours via GT for GERD, and the nurse stated she paused the tube feeding to give the medication and then resumed the feeding. Record review and staff interviews showed that pantoprazole should be given about 30 minutes before a meal and that tube feeding constitutes a meal, while sucralfate should be given on an empty stomach at least an hour before administration. RN 1 stated that giving pantoprazole with tube feeding could impair absorption and decrease therapeutic effectiveness, and that sucralfate given without an empty stomach may not coat the stomach as intended. The DON stated the physician was called to clarify how the medications were to be given, and the facility policy on enteral feeding directed that enteral feedings be held for one hour before and after a PPI dose.
Puree Diet Foods Served Too Thin and Watery
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual resident needs when residents on a puree diet were served pureed smothered rice pilaf, herb baked cod, and carrots that had a thin, watery consistency. During observation, the food items spread into one another on the plate rather than remaining as separate pureed portions, and a spoon tilt test showed the food did not hold its shape and flowed easily. The Food Services Director stated the consistency was not appropriate and that pureed foods should maintain an applesauce-like consistency, hold their shape on a spoon, and remain separate on the plate. Resident 13 was admitted with diagnoses including stroke and traumatic brain dysfunction. The resident's MDS indicated intact cognition and dependence on staff for eating, oral hygiene, bathing, and personal hygiene. Physician orders specified a puree diet with thin liquids. The facility menu for the meal listed rice pilaf, cod fillets, and carrots for residents on a puree diet, and the facility policy described pureed diet foods as blenderized or naturally pudding-like in texture to minimize chewing and increase ease of swallowing. The DON stated the puree diet consistency should not be watery and should maintain an applesauce-like consistency.
Failure to Document and Implement Two-Hour Repositioning Order
Penalty
Summary
The facility failed to ensure physician orders were implemented and documented for repositioning Resident 7 every two hours. Resident 7 was admitted and later readmitted with diagnoses including respiratory failure, traumatic brain injury, persistent vegetative state, and seizure disorder. The physician orders dated 1/22/2024 directed staff to turn and reposition the resident every two hours while in bed and provide routine skin care every two hours with turning. The care plan also identified that the resident was incontinent of bowel and included interventions to check for wetness and soiling every two hours. Resident 7's MDS dated 3/9/2026 indicated severely impaired cognitive status and dependence on staff for oral hygiene, toileting hygiene, bathing, and personal hygiene. During interview, RN 1 stated that CNAs and nurses were responsible for checking residents for wetness every two hours and that there was no documentation of staff checking for wetness every two hours. The DON stated the facility documented repositioning once per shift and not every two hours as ordered by the physician. The facility policy titled Charting Guidelines stated that all documentation would be completed as required for each resident and should include all assessments, interventions, and progress or lack of progress with the written care plan.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and preferences of one of three sampled residents, Resident 13. Resident 13 was admitted with diagnoses including stroke and traumatic brain dysfunction. The MDS dated 3/3/2026 indicated Resident 13’s cognitive functioning was intact and that he was dependent on staff for eating, oral hygiene, bathing, and personal hygiene. During an observation and interview in the activities room on 6/1/2026, Resident 13 was watching television and stated he would like more books and hands-on activities. The Activities Director stated Resident 13 liked to use an iPad, but she did not let him use it because they were watching TV, and she presented two children's books as available activity materials. During review of the monthly activity calendar on 6/4/2026, the AD identified aromatherapy as a scheduled Wednesday activity but stated the facility had run out of aromatherapy and no replacement activity had been arranged. The DON stated that if aromatherapy could not be provided, another activity should have been implemented, and that the failure to provide individualized activities can result in a decline in social, physical, and emotional functioning.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for Resident 7, who was admitted and later readmitted with diagnoses including respiratory failure, traumatic brain injury, persistent vegetative state, and seizure disorder. The resident’s care plan stated that nutritional needs could not be met independently and directed staff to monitor weight carefully and report weight loss or gain of five pounds per month, 5% or more in 30 days, or 10% in 180 days. The MDS indicated the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, bathing, and personal hygiene. The resident’s weight record showed a loss from 158 pounds on 1/2/2026 to 145 pounds on 5/7/2026, representing an 8.23% weight loss. Dietitian progress notes on 3/13/2026 and 4/13/2026 documented weights of 149 pounds and 148 pounds, respectively, with no changes recommended, and on 5/14/2026 the dietitian documented a weight of 145 pounds and recommended continuing tube feeding at 50 ml/hour for 20 hours. During interview, RN 1 stated there was no documentation addressing the resident’s weight loss, no reason documented for the reweighing on 5/7/2026, and no documentation that the significant weight loss was reported to the physician. The DON stated she would notify the physician immediately regarding the weight loss, and the facility policy required changes in resident condition to be communicated to the physician and family or legal representative.
Failure to Follow RD Recommendation for HgbA1C Monitoring
Penalty
Summary
The facility failed to provide acceptable parameters of nutrition for one resident who was admitted with severe cognitive impairment, rarely or never made self understood, rarely or never understood others, and required a feeding tube. The resident’s care plan identified the resident as at risk for nutritional deficit due to tube feeding and included an RD consult as ordered to help minimize significant weight change. Nutrition assessments documented weight loss and noted recommendations to monitor blood glucose and hemoglobin A1C because the resident had a history of diabetes mellitus, with goals to prevent further weight loss and achieve weight stabilization. A review of nurses’ notes found no documentation that the RD’s recommendation for HgbA1C was followed through, and the resident’s last recorded HgbA1C was from 10/4/2024. The facility policy stated RD recommendations for lab levels and other nutrition-related changes were to be followed and documented within one week of the initial written request.
Failure to Maintain Required Head-of-Bed Elevation During Tube Feeding
Penalty
Summary
Staff failed to follow the facility's enteral feeding protocol for a resident who had a feeding tube and was comatose, mechanically ventilated, and receiving tube feeding. The resident's physician order dated 2/12/2025 directed that the head of bed be elevated 35 to 45 degrees at all times while feeding was administered and for one hour after feeding if bolus or intermittent. The care plan for aspiration risk also included elevating the head of bed. During observation on 6/1/2026, the resident was lying on the right side in bed while Glucerna with Carbsteady 1.2 cal was infusing at 65 ml per hour, and the head of bed was observed at 25 degrees. During a concurrent interview, RN 1 confirmed the resident's head of bed was positioned at 25 degrees while receiving tube feeding and stated it should have been elevated at 35 to 45 degrees to prevent aspiration. RN 1 stated the resident was at risk for aspiration pneumonia and respiratory issues such as coughing, and later stated the intervention was not implemented for the resident. The DON also stated staff should follow the physician's order and that the head of bed needed to be at 35 degrees to prevent aspiration. The facility's enteral feeding policy stated the head of bed should be elevated 30 to 45 degrees during feedings to facilitate emptying the stomach and prevent aspiration.
Failure to Adhere to G-Tube Medication Flushing Protocols
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and facility policy for three residents who required medication administration via gastrostomy tube (g-tube). For one resident with chronic respiratory failure, ventilator dependence, and dysphagia, the physician's order and care plan required flushing the g-tube with 20-50 ml of water before and after medication administration. However, a registered nurse administered only 10 ml of water after the last medication, contrary to the order. The nurse acknowledged that this amount might not be sufficient and could result in clogging the g-tube. The Director of Subacute confirmed that the facility's policy was to flush with 30-50 ml of water after medication administration to ensure hydration and complete delivery of medication. Another resident with chronic hypoxemic respiratory failure, tracheostomy, and pneumonia also had orders to flush the g-tube with 20-50 ml of water before and after medication administration. During observation, a licensed vocational nurse administered two medications sequentially without flushing the tube in between, as required by facility policy. The pharmacist noted that the medications given had a moderate risk of interaction, and the lack of flushing could contribute to this risk, although no immediate action was required for most residents. A third resident with chronic respiratory failure, ventilator dependence, and dysphagia was also observed to have medications administered via g-tube without flushing with water between medications. The nurse involved admitted to missing the flush, and the Director of Subacute reiterated that the facility's policy is to flush with water between medications to prevent drug interactions. Review of the facility's medication administration policy confirmed the requirement to flush the tube with a minimum of 50 ml of water and to rinse the medication cup to ensure complete dosing.
Failure to Flush G-Tubes Between Medications Results in High Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 15.38% based on four medication errors out of 26 observed opportunities. The errors involved two residents who were dependent on staff for activities of daily living and had gastrostomy tubes (g-tubes) for medication and nutrition administration. Both residents had physician orders and care plans specifying that their g-tubes should be flushed with water before and after medication administration, as well as between medications, to maintain tube patency and ensure proper medication delivery. In the case of one resident, a nurse administered crushed Keppra mixed with water via the g-tube, followed by additional water to flush the remaining medication, and then administered crushed fluconazole. The nurse did not flush the g-tube with water between the two medications, contrary to facility policy and the resident's care plan. A pharmacist interview confirmed that administering Keppra and fluconazole in this manner could have moderate drug interactions, and the facility's policy required flushing between medications to prevent such issues. For another resident, a nurse administered liquid Colace followed by crushed Urecholine mixed with water through the g-tube without flushing the tube in between the two medications. The nurse acknowledged the omission during an interview, and the Director of Subacute confirmed that this was a medication error and not in accordance with facility policy. Review of the facility's medication administration policy further supported the requirement to flush g-tubes with water between medications to ensure complete dosing and prevent complications.
Failure to Label Opened Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Specifically, during a kitchen tour, a large box of sausage, a large box of bacon, and a large open carton of eggs were found unsealed and without an open or use by date written on them inside a refrigerator. The Dietary Clerk confirmed that the cook is responsible for labeling these items and acknowledged that the boxes and carton were not labeled with an open or best by date. The Dietary Clerk also stated that without an open date, the facility would not know if the food is safe to serve. The Food and Nutrition Director stated that every food item received must have a received and best by date, and every food item opened must have an open date to prevent foodborne illnesses. A review of the facility's policy and procedure on food storage indicated that food should be stored in a safe and sanitary manner to prevent contamination and that items should be rotated so the oldest dates are used first. The failure to label these food items had the potential to result in harmful bacteria growth and cross contamination, affecting at least one medically compromised resident who receives food from the kitchen.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for two residents who were dependent on staff for all activities of daily living. For one resident with chronic respiratory failure, ventilator dependence, seizure disorder, and severely impaired cognition, the care plan specifically required the call light to be within reach at all times to prevent falls or injury. However, during an observation, the call light was found hanging on the wall at the head of the bed, out of the resident's reach, after staff had finished turning and repositioning the resident. Both a CNA and an LVN confirmed that the call light should have been placed within reach before leaving the room, and acknowledged that this was not done. A second resident, also dependent on staff for activities of daily living and with diagnoses including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed lying in bed with the call light behind the head of the bed and out of reach. The care plan for this resident also required the call light to be kept within reach at all times. A CNA confirmed during the observation that the call light was not accessible and should have been placed next to the resident. Interviews with nursing staff further confirmed that facility policy and procedure required call lights to be placed within reach of residents at all times, and that failure to do so could result in a delay in care. Review of the facility's policy reiterated the requirement to always place call cords within the resident's reach, which was not followed in these instances.
Delay in Physician Notification Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the attending physician following a significant change in condition for one resident. The resident, who had a history of chronic respiratory failure, seizure disorder, traumatic brain injury, and was in a vegetative state, developed a fever and increased thick, dark yellow secretions late in the evening. Nursing documentation indicated that these symptoms were observed at 11 p.m., but there was no record of the attending physician being notified at that time. The attending physician was eventually notified approximately six hours later, in the early morning, after the resident continued to exhibit symptoms including fever, increased secretions, excessive coughing, and vomiting. At that point, the physician provided new orders for diagnostic tests and treatments, including blood cultures, laboratory tests, intravenous fluids, and antibiotics. Both the registered nurse and the director of subacute care acknowledged during interviews that the delay in physician notification was not in accordance with facility policy and could result in delayed care. Facility policy required prompt notification of the physician in the event of an acute medical change, with documentation of all attempts to notify and follow-up actions. The nurse in charge was responsible for ensuring the physician and family or legal representative were notified prior to the end of the shift when a change in condition was noted. In this case, the delay in notification was confirmed through record review and staff interviews, constituting a failure to follow established procedures for timely communication regarding changes in a resident's condition.
Failure to Float Heels as Ordered for Pressure Injury Prevention
Penalty
Summary
Facility staff failed to follow physician orders and care plan interventions for a resident with a history of a deep tissue injury on the left heel. The resident, who was dependent on staff for all activities of daily living and had significant cognitive and physical impairments, had an order and care plan in place to float her heels on two pillows to prevent pressure injuries. During an observation, it was noted that the resident's heels were resting directly on the mattress, contrary to the prescribed intervention. A registered nurse confirmed during the observation that the resident's heels were not floated as required and acknowledged that the order to float the heels on two pillows was not followed by facility staff. The facility's policy on pressure ulcer management also indicated the use of appropriate pressure relief devices, which was not implemented in this instance.
Failure to Secure Bed Brakes for Dependent Resident
Penalty
Summary
Facility staff failed to ensure that the brakes were set on the hospital bed for one of four sampled residents during a random observation. The resident involved was admitted with multiple significant diagnoses, including chronic respiratory failure requiring a ventilator, chronic encephalopathy, and dementia. The resident was documented as being dependent on staff for activities of daily living and was rarely or never able to make decisions or provide meaningful information. During an observation, the resident was found lying in bed with the bed brakes unlocked and no staff present in the room. A registered nurse, upon noticing the unlocked brakes, acknowledged that this was dangerous and could cause a fall or injury. Review of the hospital bed's operations manual confirmed that brakes should always be applied when a resident is on the bed, and staff should ensure the brakes are locked by pushing on the bed after application.
Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident who was dependent on staff for all activities of daily living and had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed with a deficiency in urinary catheter care. The resident's care plan specifically required staff to ensure that the urinary catheter tubing was not kinked and that urine could flow freely at all times to prevent infection. During an observation, the resident was found in bed with the urinary catheter tubing hanging below the bed and forming a large loop, which contained yellow liquid with sediment. A registered nurse confirmed that the tubing was looped and that urine was not draining properly, acknowledging that the tubing should be straight to allow for proper drainage. Review of the facility's catheter care policy also indicated the need to keep tubing free of kinks and obstructions. This failure to maintain proper catheter tubing positioning constituted a deficiency in providing appropriate care to prevent urinary tract infections.
Failure to Label TPN Bag and Tubing per Protocol
Penalty
Summary
Facility staff failed to administer total parenteral nutrition (TPN) in accordance with professional standards of practice for one resident. Specifically, the TPN bag and the peripherally inserted central catheter (PICC) line tubing were not labeled with the date and time they were started. This was observed during a random screening, and the omission was confirmed by a registered nurse, who acknowledged that facility policy requires all TPN bags, medications, and tubing to be labeled with the date and time to ensure proper tracking and reduce confusion among nursing staff. The resident involved had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder. The resident was dependent on staff for all activities of daily living and was rarely or never able to communicate or make decisions. The care plan for this resident included an intervention to change tubing according to protocol, but this protocol was not followed as evidenced by the lack of labeling on the TPN bag and tubing.
Failure to Label Yankauer Suction Catheter with Change Date
Penalty
Summary
A deficiency was identified when a resident who was ventilator-dependent and required frequent suctioning did not have their Yankauer suction catheter properly labeled with the date it was to be changed next. The resident had a history of respiratory failure, severe cognitive impairment, and required total assistance with all activities of daily living. Physician's orders and the care plan specified suctioning every two hours and as needed, with interventions to minimize infection risk, including regular equipment changes and labeling. During observation, the resident's Yankauer suction catheter was found inside an opened storage bag without a label indicating the date it was to be changed. Interviews with nursing staff and the Director of Sub Acute confirmed that facility policy required daily changes of respiratory equipment, with labeling to indicate the next change date and staff initials. The absence of this label meant staff could not verify when the catheter was last changed, which was inconsistent with professional standards and facility policy, and placed the resident at risk for infection from potentially contaminated equipment.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with chronic respiratory failure, ventilator dependence, and dysphagia with a gastrostomy tube, there was a discrepancy between the written physician's order and the electronic order for docusate sodium. The written order specified docusate sodium soft gel capsules to be administered via g-tube, while the electronic order listed the medication in liquid form. Observation confirmed that the liquid form was administered, and staff interviews revealed that the order should have been clarified with the physician to ensure consistency and accuracy in the resident's medical record. For another resident with acute hypoxic respiratory failure, tracheostomy, and sepsis, the medical record was inaccurate when a nurse documented the presence of bleeding and still administered Eliquis, an anticoagulant. The care plan for this resident included monitoring for signs of bleeding and holding anticoagulant therapy if bleeding was observed. Review of the Medication Administration Record showed that Eliquis was given despite documentation of bleeding, and staff interviews confirmed that the medication should have been held under these circumstances. These failures resulted in medical records containing inaccurate documentation, with discrepancies between physician orders and actual care provided. The facility's policy required accurate, factual, and specific documentation of resident conditions and interventions, which was not followed in these instances.
Failure to Monitor and Document Antibiotic Use and Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two residents by not adequately monitoring antibiotic use, side effects, or adverse reactions, and by failing to maintain complete infection control surveillance records. For one resident, who was admitted with multiple complex diagnoses including seizure disorder, traumatic brain injury, respiratory failure with tracheostomy, and was in a vegetative state, there was a documented fever and increased secretions, leading to the initiation of intravenous antibiotics (Zosyn and Vancomycin). Despite care plan interventions requiring observation for adverse reactions, there was no documentation in the nurses' notes of monitoring for antibiotic use or adverse reactions during the course of treatment. Interviews with facility staff, including the MDS nurse, Infection Preventionist, and pharmacist, confirmed that the expectation was for nurses to monitor and document antibiotic use and any side effects or adverse reactions every shift. However, this monitoring and documentation did not occur as required. The pharmacist also relied on these notes for their own monitoring, further highlighting the gap in the process. For another resident, who was also in a vegetative state and dependent on staff for all activities of daily living, the facility failed to complete the Infection Control Log related to antibiotic use for a wound infection. Key information such as date of admission, signs and symptoms, organism, and date infection resolved were missing from the log. Staff interviews confirmed that the log was incomplete and that the responsibility for documentation was not consistently followed. The facility's policy required antibiotic surveillance as part of its stewardship program, but this was not carried out as documented.
Inadequate Infection Preventionist Oversight and Incomplete Antibiotic Surveillance
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was qualified and competent in implementing the infection prevention and control program. Specifically, the IP did not monitor antibiotic use, side effects, or adverse reactions for a resident who was prescribed Zosyn and Vancomycin for a fever. Despite care plan interventions requiring observation for adverse reactions, there was no documented monitoring in the nurse's notes for the duration of the antibiotic therapy. Additionally, the facility's Infection Control Surveillance Log for another resident receiving antibiotics for a wound infection was incomplete. Key information such as date of admission, signs and symptoms, organism location, and date infection resolved were missing from the log. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that the log was incomplete for this resident. Interviews with the IP revealed that she had not started her own antibiotic surveillance log as required by her job description, and she acknowledged that the antibiotic surveillance process was not being completed. The IP also stated that she was responsible for multiple facilities and had not attended required training or conventions. The Director of Subacute and Chief Nursing Officer confirmed that the IP had not met the qualifications outlined in her job description and that the infection control tracking and monitoring duties were not being fulfilled.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement a policy and procedure on enhanced barrier precautions (EBP) designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. This deficiency was observed in four sampled residents during medication administration. The facility did not have EBP signs or isolation carts at the entrance of the residents' rooms, and staff did not don appropriate personal protective equipment (PPE) such as gowns during high-contact resident care activities. This failure was confirmed through observations, interviews, and record reviews involving Residents 10, 13, 12, and 14, all of whom had conditions that made them prone to infections, such as tracheostomies, g-tubes, and open wounds. Resident 10 was admitted with diagnoses including chronic respiratory failure, enterocolitis due to clostridium difficile, and tracheostomy status. The resident was on isolation for an active infectious disease and required various medical interventions. During medication administration, the nurse did not follow EBP protocols, such as wearing a gown, despite the resident's high risk of infection. The Nurse Manager and Infection Preventionist acknowledged the lack of EBP implementation and the absence of staff training on the procedure. Similarly, Resident 13, who had chronic respiratory failure, tracheostomy status, and g-tube status, did not have EBP signs or isolation carts in their room. The nurse administering medications did not wear a gown, and the Nurse Manager confirmed that EBP should have been implemented. Resident 12 and Resident 14, both with tracheostomies and g-tubes, also did not have EBP protocols followed during medication administration. Interviews with the Nurse Manager, Infection Preventionist, and Chief Nursing Officer revealed that the facility was aware of the need for EBP but had not yet developed or implemented the necessary policies and procedures.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to provide care in accordance with professional standards to three residents by not rotating subcutaneous injection sites for medications. Resident 7, who had diagnoses including hemiplegia, anoxic brain damage, and circulatory system diseases, received repeated heparin injections in the same areas, leading to potential risks of bruising and bleeding. The Medication Administration Record showed that injections were not rotated on multiple dates, and this was confirmed by the Minimum Data Set Coordinator-Registered Nurse (MDSC-RN) and the Nurse Manager (NM). The facility's policy and prescribing information for heparin also indicated the need for site rotation to prevent such issues. Resident 9, diagnosed with anemia, coronary artery disease, and in a persistent vegetative state, also received repeated enoxaparin sodium (Lovenox) injections in the same areas. The MDSC-RN verified that the injection sites were not rotated on several dates, which was corroborated by the Pharmacist (PHARM 1) and the NM. The facility's policy and the prescribing information for enoxaparin sodium highlighted the importance of alternating injection sites to prevent complications. Resident 13, who had diabetes mellitus, malnutrition, and dysphagia, received repeated Lantus insulin injections in the same areas. The MDSC-RN confirmed that the injection sites were not rotated on numerous dates, and this was supported by PHARM 1 and the NM. The facility's policy and the prescribing information for Lantus emphasized the need for site rotation to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon the recommendations of the consultant pharmacist for two of five sampled residents. For Resident 2, the facility did not taper down the dosage of methadone as recommended by the pharmacist. Despite the pharmacist's recommendation to reduce the dosage to 10 mg every 24 hours, the physician continued the existing pain management regimen without documenting the rationale for not following the recommendation. The pharmacist also failed to document her conversation with the physician regarding the recommendation, leaving the healthcare team unaware of the rationale for not tapering the medication. For Resident 17, the facility did not document episodes of respiratory distress or heart rate greater than 120 in the electronic medication administration record (eMAR) when administering lorazepam. The medication was administered on multiple occasions without documented evidence of the required conditions being met. This lack of documentation prevented the care team from assessing the necessity of the medication and ensuring it was used appropriately. For Resident 7, the facility did not act upon the pharmacist's recommendation to consider discontinuing Robitussin if it was not being used. The medication order remained active without a stop date, and there was no documentation indicating that the recommendation was communicated to the physician or acted upon. This oversight could lead to the resident receiving unnecessary medication and potential side effects from prolonged use of Robitussin.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous injection sites for three residents. Resident 7, who had diagnoses including hemiplegia, anoxic brain damage, and circulatory system diseases, received repeated heparin injections in the same areas, leading to potential bruising and bleeding. The Medication Administration Record showed multiple instances where the injection sites were not rotated as required, which was confirmed by the Minimum Data Set Coordinator-Registered Nurse (MDSC-RN) and the Nurse Manager (NM). Both acknowledged that not rotating the injection sites is considered a medication error. Resident 9, diagnosed with anemia, coronary artery disease, and in a persistent vegetative state, also received repeated enoxaparin sodium (Lovenox) injections in the same areas. The MDSC-RN verified that the injection sites were not rotated, and this was confirmed by both the pharmacist and the NM. The facility's policy and the prescribing information for enoxaparin sodium both indicated the necessity of rotating injection sites to prevent adverse effects. Resident 13, who had diabetes mellitus, malnutrition, and dysphagia, received repeated Lantus insulin injections in the same areas. The MDSC-RN confirmed that the injection sites were not rotated, and this was corroborated by the pharmacist and the NM. The facility's policy and the prescribing information for Lantus emphasized the importance of rotating injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. The failure to rotate injection sites for these residents was identified as a significant medication error by the surveyors.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation and interview with the Director of Food and Nutrition (DFN), it was noted that the ice scooper was stored in an uncovered holder mounted on the side of the machine. The DFN acknowledged that the ice scooper should be stored in a closed container to prevent outside contaminants from settling in the scooper, which could cause foodborne illnesses. Additionally, Food Service Worker 1 (FSW 1) was observed not wearing a hairnet while inside the kitchen. The DFN confirmed that FSW 1 should wear a hairnet at all times when working in the kitchen to prevent hair from contaminating food and equipment, which could result in serving contaminated food to residents. Furthermore, an opened container of canola/extra virgin olive oil was found without an open date label. The DFN stated that the container should have an open date label to inform kitchen staff when to discard the oil. The absence of this label could potentially result in staff using expired oil, leading to foodborne illnesses among residents. The facility's policies and procedures, including those for dispensing ice, dress code, and food labeling and dating, were reviewed and found to support the need for these practices to prevent contamination and ensure food safety.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Firstly, the barcode scanner used during medication administration was not sanitized before and after use, potentially causing cross-contamination between residents. This was observed during medication administration for two residents, where the Licensed Vocational Nurse (LVN) did not clean the scanner after placing it on a resident's tablet and before using it on another resident. The Nurse Manager confirmed that the barcode scanners should be disinfected between uses to prevent the spread of infections, but this practice was not followed by the LVN. Secondly, the facility did not implement Enhanced Barrier Precautions (EBP) during gastrostomy tube medication administration for residents with indwelling devices. The LVN administered medications to residents without donning an isolation gown, despite the residents having conditions that made them prone to infections. Both the Nurse Manager and the Infection Preventionist acknowledged that EBPs should be used for residents with wounds or indwelling devices, but the facility had not implemented this practice. The Chief Nursing Officer also confirmed that the EBP policy was not finalized or implemented, despite being aware of its importance. Lastly, the facility failed to discard opened and partially used normal saline solution unit dose vials after use. During an observation, two opened vials were found inside a box, which were supposed to be single-use only. Both a Registered Nurse and a Respiratory Therapist confirmed that these vials should have been discarded after use to prevent infection. The facility's policy also indicated that single-use items should be discarded after use, but this was not adhered to, posing a risk of infection to the residents.
Failure to Implement Enhanced Barrier Precaution Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan on enhanced barrier precaution isolation for two residents, leading to potential infection control issues. Resident 10, admitted with chronic respiratory failure, enterocolitis due to clostridium difficile, and tracheostomy status, did not have an enhanced barrier precaution sign or isolation cart outside their room. During medication administration, the Licensed Vocational Nurse (LVN) did not wear a gown, and it was confirmed that Resident 10's care plan did not include enhanced barrier precautions, which was acknowledged as important by both the LVN and the Nurse Manager (NM). Similarly, Resident 13, admitted with chronic respiratory failure, tracheostomy status, and gastrostomy status, also lacked an enhanced barrier precaution sign and isolation cart outside their room. The same LVN did not wear a gown during medication administration for Resident 13, and it was confirmed that Resident 13's care plan did not address enhanced barrier precautions. The facility's policy required a comprehensive care plan to be developed within seven days of admission and updated regularly, but this was not followed for these residents. The observations and interviews revealed that the facility did not adhere to its own care planning policies, which required the development of a coordinated and comprehensive written plan based on the resident assessment and individual needs. This failure to implement appropriate infection control measures had the potential to spread infection among residents and staff, as evidenced by the lack of enhanced barrier precaution care plans for Residents 10 and 13.
Failure to Prevent Accidents Due to Unattended Medication
Penalty
Summary
The facility failed to ensure residents received adequate supervision to prevent accidents by leaving a medication cup containing clear and white ointment unattended and readily accessible in a shared room. This incident involved two residents, one of whom was in a persistent vegetative state and totally dependent on staff for all activities of daily living, while the other resident was sometimes able to make himself understood and also totally dependent on staff for mobility and hygiene. Both residents had physician orders for the application of ointments for skin management and maintenance, which were not properly administered and monitored by the staff. During an observation, a Certified Nursing Assistant (CNA) found a medication cup with ointments on a wall-mounted workstation in the shared room of the two residents. The CNA did not know who placed the cup there and stated that ointments should be discarded after each use and not left in residents' rooms. Further interviews with a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) confirmed that the medication cup was not labeled, and it was against facility policy to leave medications in residents' rooms due to the risk of accidental ingestion. The Nurse Manager reviewed the facility's policy and procedure regarding medication administration, which indicated that medications should not be left with residents to self-administer unobserved. The policy was not followed in this instance, leading to a potential risk for the residents. The facility's failure to adhere to its medication administration policy resulted in a deficiency that could have caused harm to the residents involved.
Failure to Administer and Document IV Fluids Properly
Penalty
Summary
The facility failed to administer parenteral fluids consistent with professional standards of practice for two residents. For Resident 1, the facility did not label the midline catheter dressing with the date of the last dressing change. This was observed during a bedside check, and the registered nurse confirmed the omission. The facility's policy requires midline catheter dressings to be changed every seven days and as needed, and the absence of a date on the dressing could lead to untimely changes and potential infection. The resident had severe cognitive impairment and required total assistance with all activities of daily living, making proper catheter care crucial. For Resident 2, the facility failed to document midline catheter care and dressing changes as per the facility's policy. The resident's midline catheter dressing was observed to be dated, but there was no documented evidence of the dressing change in the nursing records. Additionally, there was no documentation of midline catheter care for specific shifts. The registered nurse verified these documentation gaps, which are against the facility's policy that mandates documenting all assessments and interventions. Resident 2 had intact cognition but required total assistance with all activities of daily living, and proper documentation is essential to ensure timely and appropriate care. Both residents had physician's orders for midline catheter care, including dressing changes every seven days and flushing with normal saline every shift. The facility's failure to adhere to these orders and document the care provided placed the residents at risk for complications such as infection. The facility's policies on midline catheter management and charting guidelines were not followed, leading to these deficiencies.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe provision of pharmaceutical services during an inspection of Medication Cart 2. An opened and unlabeled single-use vitamin A&D ointment packet was found in the top drawer of the cart. The Licensed Vocational Nurse (LVN) present during the inspection stated that the ointment packet should have been discarded after use in the resident's room. The LVN did not know which resident the packet was opened for or if it had been used, indicating a lapse in proper medication handling procedures. The Nurse Manager confirmed that such ointment packets are not meant for multiple residents and should be labeled with the resident's name if unused and opened in the medication cart. A review of the facility's policies indicated that drugs and devices should be stored to ensure stability and integrity, and that all medications must be appropriately labeled to promote safety. The facility's policy on medication storage and labeling was not followed, as evidenced by the presence of the opened and unlabeled ointment packet. This failure had the potential to result in cross contamination and decreased efficacy of the medication, posing a risk to resident safety.
Failure to Maintain Nebulizer Compressor
Penalty
Summary
The facility failed to maintain a handheld nebulizer compressor in safe operational condition for a resident in a persistent vegetative state. The nebulizer compressor, which was essential for administering respiratory treatments, was labeled with a next inspection due date of July 2023 but had not been inspected by the time of the survey in April 2024. This oversight was identified during an observation of the resident's environment and confirmed through interviews with nursing and respiratory therapy staff, who acknowledged the lapse in inspection and maintenance protocols. The resident, who was totally dependent on staff for all activities of daily living, had multiple physician orders for routine and as-needed nebulizer treatments to manage respiratory conditions. Despite these orders, the nebulizer compressor had not been inspected as required, potentially compromising the effectiveness of the resident's respiratory care. Staff interviews revealed a lack of clarity regarding the responsibility for ensuring the equipment was inspected, with both nursing and respiratory therapy staff assuming the other party would handle it. Further investigation with the Biomed Engineering Site Lead revealed that the nebulizer had been placed in out-of-service status because it had not been located for inspection. The facility's Environment of Care Manual indicated that medical equipment should be inspected, tested, and maintained regularly, but this protocol was not followed in this case. The failure to inspect the nebulizer compressor as scheduled was attributed to an oversight and a breakdown in communication among staff responsible for the equipment's maintenance.
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What surveyors actually found near you
We read the 6,049 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
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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 Health & Rehab | 0 mi | ★★★★★ | 28 | 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 |
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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.