SHERMAN OAKS, CA - A March 2025 inspection at Sherman Oaks Health & Rehab revealed significant deficiencies in resident care, medication management, and safety protocols that potentially impacted resident health and quality of life.
Failure to Honor End-of-Life Wishes Results in Unwanted CPR
The most serious violation involved a devastating failure to respect a resident's documented end-of-life preferences. A resident with dementia and other serious conditions had previously signed a Do Not Resuscitate (DNR) order requesting no CPR. However, when facility staff filed the resident's advance directive paperwork in an old chart instead of the current medical record, nursing staff were unaware of the resident's wishes.
When the resident was found unresponsive with no vital signs on the evening in question, staff immediately began chest compressions and called a "code blue" emergency. Paramedics continued CPR for 25 additional minutes before the resident was pronounced dead at 7:50 p.m.
The facility's MDS Nurse acknowledged the critical error: "If this was not filed in the resident's current chart the resident could be considered full code status," explaining that the misfiled paperwork essentially nullified the resident's documented wishes. The Social Services Director admitted she "missed it and the resident received CPR who had a DNR order."
This violation represents a fundamental breach of resident rights and dignity. Advanced directives exist specifically to ensure individuals' end-of-life preferences are respected during medical emergencies. When healthcare facilities fail to properly maintain and access these critical documents, residents may receive unwanted life-sustaining treatments that directly contradict their personal values and previously expressed wishes.
The medical consequences extend beyond the immediate trauma. Performing CPR on individuals with advanced dementia and multiple comorbidities often proves futile while potentially causing additional physical trauma including rib fractures and other injuries. Moreover, the emotional impact on family members who believed their loved one's wishes would be honored cannot be understated.
Widespread Medication Consent Violations Compromise Informed Care
Inspectors identified systematic failures in obtaining proper informed consent for psychotropic medications across multiple residents. These powerful psychiatric drugs, which can significantly alter brain function and behavior, were administered without completing required consent processes that ensure residents and families understand the risks and benefits.
For one resident taking antidepressant and sleep medications, the informed consent forms lacked required signatures from both the prescribing physician and the resident's representative. The facility's Director of Nursing confirmed: "The prescribing doctor explains the risk and benefits of taking the psychoactive medications and the licensed nurses will follow up if the resident or resident representative consented to its use."
Another resident received two different psychotropic medications - sertraline for depression and divalproex sodium for mood swings - without any documented informed consent. The medications were being administered three times daily and daily respectively, despite no evidence that the resident's representative had been informed of potential side effects or given the opportunity to refuse treatment.
Proper informed consent for psychiatric medications is medically essential because these drugs can cause serious side effects including dizziness, falls, cognitive impairment, and potentially dangerous drug interactions. Without informed consent, residents may receive medications against their preferences, potentially causing harm while violating their fundamental right to make healthcare decisions.
The facility's own policy requires physicians to explain potential side effects, drug interactions, FDA warnings, and monitoring plans before prescribing psychotropic medications. Licensed nurses must then verify consent was obtained. When these protocols fail, residents lose crucial protections against inappropriate psychiatric drug use.
Safety Equipment and Environmental Hazards Create Risk
Multiple safety and environmental violations created potential hazards for vulnerable residents. Inspectors found call lights - essential safety devices that allow residents to summon help - were not within reach for residents who needed them.
One resident with a history of falls and significant cognitive impairment had their call light hanging on the wall hook, completely inaccessible while lying in bed. Another resident's call light was observed on the floor beside the bed, creating both an accessibility issue and a potential tripping hazard.
Call lights represent a critical safety lifeline for nursing home residents, many of whom have limited mobility and serious medical conditions. When these devices are not within reach, residents cannot alert staff to medical emergencies, falls, or other urgent needs. This can delay critical care and potentially result in preventable injuries or deaths.
The facility also failed to maintain a safe physical environment in resident rooms. One resident's room contained a damaged baseboard with exposed nails protruding approximately one inch into the room near the wheelchair area, broken concrete pieces on the floor, and a splintered windowsill with jagged wood edges. Unexplained red letters "F-L-A-I" were stenciled on the wall above the resident's bed.
These conditions violate requirements for nursing homes to provide a safe, clean, and homelike environment. Sharp objects, debris, and disrepair create obvious injury risks while also negatively impacting residents' emotional well-being and quality of life.
Physical Restraint Violations Restrict Resident Movement
Inspectors documented improper use of physical restraints that restricted residents' freedom of movement without proper medical justification or oversight. One resident had pillows tucked under the fitted sheet on both sides of the bed, creating barriers that prevented normal movement.
The certified nursing assistant acknowledged this was "a form of restraint" used because the resident "had multiple attempts of dangling his legs on the side of the bed." However, no physician's order, restraint assessment, informed consent, or care plan existed to justify this restrictive intervention.
Another resident had a bed alarm attached without any of the required documentation or assessments. Federal regulations require comprehensive evaluation, physician orders, informed consent, and ongoing monitoring before any restraint use.
Physical restraints in nursing homes carry significant medical risks including muscle weakness, pressure sores, psychological distress, and functional decline. They should only be used when medically necessary and after less restrictive alternatives have been exhausted. Improper restraint use violates residents' rights and can cause serious harm.
Additional Issues Identified
The inspection revealed several other concerning violations including failure to post recent survey results where residents could access them, improper medication monitoring protocols, inaccurate resident assessments, and delayed completion of required documentation. The facility also failed to provide required bed-hold notifications when residents were transferred to hospitals.
These systematic deficiencies suggest broader issues with staff training, policy implementation, and quality oversight at Sherman Oaks Health & Rehab that require immediate attention to protect resident safety and rights.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Oaks Health & Rehab from 2025-03-14 including all violations, facility responses, and corrective action plans.
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