Treatment Nurse 1 was caring for Resident 13, who has dementia and a history of falls, when federal inspectors observed the March 13 incident at Sherman Oaks Health & Rehab. The resident was lying on her side, holding the bed rail, with her bed elevated to its highest position when the nurse walked away to wash his hands.
"TN 1 stated it was not okay to leave Resident 13 unattended with the bed in the high position because the resident may move and fall off the bed causing an injury," according to the inspection report.
The nurse left the 78-year-old resident alone while the bed remained elevated after cleansing her sacral wound, after applying dressing, after cleaning her left heel wound, and after applying ointment. Each time, he walked to the bathroom with the privacy curtain closed, making the resident invisible from the hallway.
During the immediate post-treatment interview, the nurse acknowledged the resident "is able to move a bit" and was "confused." He said he usually brings a certified nursing assistant to help with wound care, but all the CNAs were busy that day.
Director of Nursing confirmed the policy violation during her March 14 interview. She said Resident 13 "is able to wiggle and the resident is unpredictable" and "should not be left unattended with the bed in the high position because the resident could roll off the bed resulting in injury."
The DON identified three alternatives the nurse should have used: bringing a CNA into the room, lowering the bed when washing hands, or using antibacterial hand rub at bedside.
Resident 13 was admitted in 2016 and readmitted in 2019 with diagnoses including dementia, muscle weakness, pressure-induced tissue damage of the sacral region, and history of falling. Her December 2024 assessment indicated she lacked capacity to understand and make decisions.
The facility had implemented a "Falling Star Program" for the resident in January, with orders for a low bed with floor mats "to decrease the potential for injury due to unpredictable movement related to dementia."
Federal inspectors documented additional safety violations throughout the 91423 facility during their March inspection.
Fall mats rendered useless by furniture became a pattern. Resident 88, admitted in 2023 with dementia and fall history, had bilateral fall mats blocked by a wheelchair, side table, and visitor chair. The Assistant Director of Staff Development stated during the March 12 observation that "there should be no furniture or medical equipment on top of Resident 88's fall mats because the resident can fall on them and cause injury."
Registered Nurse 1 explained the consequences: residents "can fall on them and cause injuries such as head bumps, fracture, skin lacerations and cuts." The nurse added that heavy equipment creates permanent dents in the mats, "decreasing the ability of the mat to lessen the impact of the fall."
Resident 272, admitted March 3 with walking difficulties and muscle weakness, faced similar obstacles. Inspectors found equipment placed on top of the resident's floor mats, and the required bed tab alarm was missing entirely.
Urinary catheter care violations affected multiple residents. Resident 272's suprapubic catheter tubing was coiled at the lower end with urine backing up inside. The Infection Preventionist stated during the March 11 observation that catheters "should be placed in a position that the urine will drain freely such as no kinks or loops and can cause the urine to backflow which may lead to a UTI."
Resident 371, admitted March 11 with prostate problems, had similar catheter tubing issues. A certified nursing assistant acknowledged the tubing "should not be coiled to prevent backflow of urine to the bladder causing infection."
Oxygen therapy documentation failures created treatment gaps for multiple residents. Resident 74, with Alzheimer's disease and metabolic encephalopathy, received oxygen continuously but nurses failed to document 42 separate administrations between January and March in the medication administration record.
Licensed Vocational Nurse 2 reviewed the resident's records and admitted she "did not know why she did not document Resident 74's O2 PRN in the MAR, but she should have." The nurse acknowledged that without documentation, "it is important to document the amount of O2 the resident receives, monitor for the effectiveness of the PRN O2, and document when the O2 was removed."
Resident 70 faced identical documentation problems. Inspectors observed the resident on continuous oxygen March 11 and 12, but found no medication record entries despite facility policy requiring such documentation.
Registered Nurse 1 explained the clinical risks: "when the licensed nurses administer the oxygen therapy and does not document in the MAR, the resident could be given oxygen unnecessarily" and "could potentially not get the proper and timely treatment."
Contaminated oxygen equipment posed infection risks. Resident 96's oxygen tubing was observed touching the floor, prompting the Assistant Director of Staff Development to state that "using a contaminated oxygen tubing that has touched the floor can cause respiratory infection."
Nutritional supplement failures affected weight-loss patients. Resident 42, whose weight dropped from 195 pounds to 144 pounds, was prescribed Ensure twice daily but didn't receive it during the March 11 inspection. The resident told inspectors he used to see his nutritional drink "in the morning after breakfast but before his lunch" but noticed it missing from his table.
Licensed Vocational Nurse 1 admitted she "missed giving it to the resident" and stated that without the supplement, the resident "could potentially lose more weight."
Medication accountability failures involved controlled substances. During a March 12 medication cart inspection, Licensed Vocational Nurse 3 couldn't account for missing doses of three controlled medications: Belbuca for Resident 5, hydrocodone for Resident 97, and pregabalin for Resident 272.
The nurse admitted she "administered" the medications that morning but "forgot to sign the Antibiotic or Controlled Drug Record accountability logs." She acknowledged this could "lead to medication error if overdosed leading to stoppage of breathing, hospitalization, and possibly death."
Post-dialysis assessment gaps affected Resident 5, who receives hemodialysis three times weekly. The Minimum Data Set Nurse reviewed communication records and found incomplete assessments on eight separate dates between February and March, missing evaluations for bleeding, cognitive status, and proper arteriovenous shunt function.
The Director of Nursing emphasized that immediate post-dialysis assessment is "important to catch any changes of condition in a timely way to treat the resident and prevent a further decline."
Bed rail safety evaluations were two years overdue for Resident 88. Despite facility policy requiring quarterly entrapment assessments, the last evaluation was completed February 21, 2023. The resident remained on bilateral upper side rails with bilateral floor mats throughout the inspection period.
IV line maintenance violations created infection risks. Resident 269's PICC line dressing was loose and soiled during the March 11 observation, with the resident explaining he "had a shower the day before and the dressing became loose." Registered Nurse 1 stated the dressing "should have been changed when the night shift RN hang the new bag of IV antibiotic at 7 a.m."
Resident 15's peripheral IV line lacked a sterile injection cap over the needleless port. The nurse explained that "any IV access with needleless injection ports should be covered with a sterile injection cap after each use" to prevent infection.
The consultant pharmacist failed to identify monitoring gaps for two residents taking blood-thinning medications. Resident 42 was prescribed both clopidogrel and Eliquis without documented bleeding monitoring, while Resident 79 received atorvastatin without required lipid panel monitoring.
Sherman Oaks Health & Rehab operates at 14401 Huston Street and was cited for minimal harm violations affecting multiple residents across care areas including accident prevention, respiratory care, medication management, and clinical assessments.
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.