Resident 115 was found unresponsive at Sherman Oaks Health & Rehab at 7:20 p.m. on an undisclosed date. Nurses started chest compressions and announced a code blue. Paramedics arrived and continued CPR for another 25 minutes before stopping resuscitation efforts at 7:50 p.m. The resident was pronounced dead.
The resident's family had signed a Preferred Intensity of Care form authorizing no CPR. The document stated the resident was not capable of making medical decisions and requested that withholding CPR was consistent with the resident's views.
But the form was buried in an old chart from a previous stay.
"I missed it and the resident received CPR who had a DNR order," Social Services Director told inspectors during the March investigation.
The resident had been readmitted to the facility after a previous discharge. Staff filed the DNR paperwork in the old chart instead of transferring it to the current medical record. Without the form visible in the active chart, nurses treated the resident as "full code status" during the medical emergency.
MDS Nurse 1 explained the filing error to inspectors: "This should have been filed in the resident's current closed chart when he was readmitted. It was filed in the resident's old chart with discharge date."
The nurse said this prevented facility staff from knowing the resident's preferred treatment. "If this was not filed in the resident's current chart the resident could be considered full code status."
Resident 115 had been admitted originally to Sherman Oaks with metabolic encephalopathy, sepsis, and dementia. Medical records showed the resident had severely impaired cognitive skills for daily decision making and rarely made himself understood or understood others.
The Social Services Director told inspectors she had documented informing the resident's representative that the resident would remain full code status until new advance directive paperwork was completed. She said she should have asked medical records to check for the previous DNR form.
"When the resident's signed PIC Authorization/Decisions form was not filed on the resident's chart the resident will not receive their preferred care and their resident's rights of preferred treatment would not be followed and respected," the Social Services Director admitted.
The Director of Nursing said following up on advance directives should happen immediately upon admission. "It is very important to follow upon the resident's admission and ask the medical record staff to bring up the resident's preferred intensity of treatment in the new chart because it reflects the resident's wishes."
She said if weekend admissions prevent immediate review, staff should check hospital records for code status orders.
The facility's own policy states that DNR orders remain in effect until the resident or legal surrogate provides a signed request to end the DNR order. The policy emphasizes that no one is required to complete advance directive forms as they are "100% voluntary."
In a separate violation, the facility failed to complete required change-of-condition assessments when residents experienced medical emergencies requiring hospitalization.
Resident 3 was transferred to acute care on August 25, 2024, for elevated white blood cell count and abnormal lab values suggesting acute kidney failure and infection. Licensed Vocational Nurse 2 noted at 6:27 a.m. that "the resident was sent out to the hospital." The discharge summary listed the transfer reason as elevated white blood cells requiring evaluation for kidney failure and infection.
But no nurse completed a change-of-condition report documenting the events leading to hospitalization.
Registered Nurse 1 told inspectors: "I cannot find any Change of Condition Report done by licensed nurses on 8/25/2024. The licensed nurse who discharged the resident to the acute care hospital should have done a change of condition report to document the incident to communicate the event to other healthcare providers."
The Director of Nursing confirmed the oversight: "The licensed staff should have created a change of condition report for Resident 3, who went to the hospital on 8/25/2024 due to elevated WBC to document the events that happened, and the interventions provided to the resident prior to transfer."
The facility's policy requires nurses to assess and document baseline information including vital signs, neurological status, pain levels, consciousness, and recent lab results before contacting physicians about condition changes.
Inspectors also found multiple safety hazards that put vulnerable residents at risk of injury during falls.
Three residents with high fall risk had safety equipment rendered useless by staff who placed furniture and equipment on top of protective floor mats.
Resident 4, who has dementia and is totally dependent on staff for all activities, had physician orders for bilateral floor mats to prevent injury from unpredictable movements. But inspectors found a wheelchair sitting on the right floor mat and an overbed table on the left mat during multiple observations.
Certified Nursing Assistant 4 told inspectors the wheelchair "has been there since she clocked in." She said she knew the floor mats were "to prevent the resident from falling directly on the floor because the resident is a fall risk" but didn't know if equipment could be placed on them.
Licensed Vocational Nurse 1 was more direct: "The fall mat should not have anything on top of it because it defeats the purpose of preventing injury to the resident. The resident could fall and hit themselves on the wheelchair."
Resident 272, admitted after a fall with muscle weakness and walking difficulty, had similar problems. Inspectors observed the overbed table placed on the left floor mat while the right mat was pushed halfway under the bed with a bed wheel on top of it. The resident also lacked the ordered tab alarm to alert staff when attempting to get up.
The Infection Preventionist explained the safety compromise: "Any heavy equipment placed on top of the floor mat and not placed appropriately can affect the integrity of the floor mat which defeats the purpose of providing safety for the resident during falls."
The most dangerous hazard involved Resident 70, a woman with dementia who cannot communicate or care for herself.
Maintenance staff had removed baseboard trim from the wall next to her bed, leaving a large metal nail extending approximately one inch into the room near her wheelchair. The windowsill above was broken with jagged, splintering wood. Pieces of broken concrete littered the floor beneath.
The Maintenance Director admitted leaving the hazards in place for about a week while waiting to complete repairs. "The MD did not think the environment was unsafe for the resident," according to the inspection report.
Three different nursing assistants entered the room during inspections and expressed surprise at the dangerous conditions. None had reported the hazards despite the facility's policy requiring staff to identify and report accident hazards.
The Director of Nursing was equally unaware of the situation until inspectors showed her the room. "The resident's room had hazards and should have been reported and corrected immediately, but it was not," she acknowledged.
She noted the potential for Resident 70 to suffer cuts from the protruding nail during wheelchair transfers. "The facility policy was not followed."
The Assistant Director of Staff Development assessed the scene and concluded: "The broken baseboard and windowsill did not look safe and should not be like that. The nails could be a danger to any resident passing by."
All violations occurred at a facility that admits some of California's most vulnerable residents. The three residents with compromised safety equipment required substantial to total assistance with daily activities. Resident 70 cannot communicate her needs or understand others.
The facility's own policies emphasize resident safety as a "facility-wide priority" and require staff to make the environment "as free from accident hazards as possible."
But Resident 115's family watched their loved one receive 25 minutes of unwanted medical intervention because of a filing error. The resident had signed paperwork refusing such treatment, understanding it was consistent with their wishes for end-of-life care.
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.