Sherman Village Hcc

During a review of the facility policy and procedure titled, Call Lights, last reviewed 7/25/2024, the policy indicated call lights assure residents receive prompt assistance.

All staff shall know how to place the call light for a resident and how to use the call light system.

Nursing and care duties include insuring that the call light is within the resident's reach when in his/her room.

During a review of the facility policy and procedure titled, Falls and Fall Risk, Managing, last reviewed 7/25/2024, the policy indicated based on evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

a place readily accessible to residents and must post a notice of their availability.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility's P&P titled, Homelike Environment, last reviewed 7/25/2024, the P&P indicated the facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutionalized setting.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During an interview with the Director of Nursing (DON), on 9/6/2024, at 2:01 p.m., the DON stated placing pillows underneath the mattress and side rails can be considered restraints.

The DON stated when using restraints, an informed consent, an assessment, and physician's order is needed to inform the staff, resident, and responsible person of the intervention, to see if the restraint is needed or not, and to determine the safety of the resident.

The DON stated even if the use of restraints is a family request, an informed consent, an assessment, and physician's order is needed.

The DON stated informed consents inform the resident and the responsible person of the risks and benefits of the restrain being applied.

The DON further stated Resident 37 did not have an order for the use of pillows underneath the mattress and bed rails.

During a review of the facility's policy and procedure (P&P) titled, Physical Restraint, last reviewed 7/25/2024, the P&P indicated the licensed nurse shall be responsible for obtaining an order from the attending physician which is to include the specific type of restraint, purpose of the restraint, time, and place of application, approaches to prevent decreased functioning when applicable, informed consent obtained from the resident or from the surrogate decision-maker.

The P&P indicated the licensed nurse shall complete the informed consent acknowledgement form.

The P&P further indicated licensed nurses are to document weekly in the licensed nurse's notes the use and effectiveness of physical restraints.

During a review of the facility's P&P titled, Bed Safety and Bed Rails, last reviewed 7/25/2024, the P&P indicated the use of bed or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During an interview with Family Member (FM) 2, on 9/5/2024, at 2:53 p.m., FM 2 stated she is the

because the resident jumps out of the bed. FM 2 further stated she and the facility staff place the pillows underneath Resident 37's mattress.

During an interview with CNA 9, on 9/6/2024, at 9:07 a.m., CNA 9 stated she was assigned to Resident 37. CNA 9 stated Resident 37 attempts to jump out of his bed and pillows are placed underneath Resident 37's mattress to position his mattress at an angle so that the resident is more toward the wall of the room and to protect the resident.

During a concurrent observation and interview with the Minimum Data Set Coordinator (MDSC), on 9/6/2024, at 9:27 a.m., inside Resident 37's room, the MDSC confirmed Resident 37 had pillows placed underneath the right side of his mattress and that the pillows should not be placed there because it can be considered a restraint.

The MDSC stated there have been instances where Resident 37 attempts to roll out of bed and the pillows placed under the mattress help keep him in place.

The MDSC confirmed Resident 37 had quarter bed rails on the left and right side of his bed.

The MDSC stated as long as there is an order for use of bed rails as an assistive device, bed rails are not considered a restraint.

The MDSC reviewed Resident 37's Order Summary Report, with orders active as of 9/6/2024, and confirmed Resident 37 did not have orders to place pillows underneath the resident's mattress and orders for use of bed rails and stated because the resident does not have an order, the bed rails and pillows are considered a restraint.

The MDSC reviewed Resident 37's MDS, dated [DATE], and confirmed the MDS section for restraints did not indicate Resident 37 used bed rails or other types of restraints.

The MDSC further stated Resident 37 has been using bed rails since before 5/24/2024 and that the restraints should have been coded into the MDS.

During an interview with the Director of Nursing (DON), on 9/6/2024, at 2:01 p.m., the DON stated it is important to have an accurate MDS because it provides a clinical picture of the resident and the information from the MDS can be used to develop a plan of care.

During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, last reviewed 7/25/2024, the P&P indicated the MDS shall be completed for each resident and sources of information to complete the MDS include review of residents' records, including hospital discharge records, communication with the resident, observations and/or assessments of the resident, communication with health providers, communications with physicians, and communications with the family.

The P&P further indicated the comprehensive assessment shall be used to develop a comprehensive care plan to allow the resident to reach his or her highest practicable level of physical, mental, and psychosocial functioning.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a concurrent interview and record review on 9/4/2024 at 9 a.m., the MDSC reviewed Resident 52's PASARR Level 1 Screening, dated 1/3/2022 and Admitting Diagnoses.

The MDSC stated upon a resident's admission, she reviews the PASARR for the need for a Level II evaluation.

The MDSC stated she will check the Level 1 Screening for accuracy by cross referencing with the resident's clinical documents.

The MDSC stated if the Level 1 Screening is not accurate the process is to clarify the diagnosis with the doctor, interview the resident, and then update the PASSR with the change of condition.

The MDSC stated if the Level 1 Screening becomes positive then a Level 2 evaluation will need to be completed to determine the services to provide to the resident.

The MDSC stated Resident 52's Level 1 Screening was not correct because the resident was readmitted on [DATE] with new diagnosis of a mood disorder and the Level 1 screening was negative and needed to be corrected, but it was not done due to an oversight.

The MDSC stated the potential negative affect would be that the resident was not provided the proper mental health care.

During a concurrent interview and record review on 9/5/2024 at 1:50 p.m., with the Director of Nursing (DON), reviewed the facility policy and procedure regarding behavioral health.

The DON stated it was important to assure the accuracy of the PASARR Level 1 Screening for mental health disorders because it facilitates the proper plan of care for the resident and the Level II evaluation would provide additional services.

The DON stated Resident 52 had a mental health issue and would benefit from any additional mental health services, but the facility policy was not followed to ensure the resident received the Level II evaluation.

During a review of the facility policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, last reviewed 7/25/2024, the policy indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Residents will have minimal complications associated with the management of altered or impaired behavior. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of mental health disorders and altered behaviors.

All residents will receive a Level 1 PASARR screen prior to admission. If the level 1 screen indicates the individual may meet the criteria for a mental disorder or related condition, he or she will be referred to the state PASARR representative for a Level II screening process.

New onset or changes in behavior that indicate newly evident or possible serious mental disorder or related disorder will be referred for a PASARR Level II evaluation.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a concurrent observation and interview with the Minimum Data Set Coordinator (MDSC), on 9/6/2024, at 9:27 a.m., inside Resident 37's room, the MDSC confirmed Resident 37 had pillows placed underneath the right side of his mattress and that the pillows should not be placed there because it can be considered a restraint.

The MDSC stated there have been instances where Resident 37 attempts to roll out of bed and the pillows placed under the mattress help keep him in place.

The MDSC reviewed Resident 37's Care Plans, active as of 9/6/2024, and the MDSC confirmed Resident 37 did not have care plans related to the placement of pillows underneath the resident's mattress.

The MDSC further stated Resident 37 should have a care plan to make sure there are interventions to monitor the resident, make sure the facility staff are aware of the plan, and to help guide the facility staff to provide proper care.

During an interview with the Director of Nursing (DON), on 9/6/2024, at 2:01 p.m., the DON stated the purpose and importance of care plans is to identify issues existing to the resident, to make a plan to assist the resident, and to have a goal to provide optimal care to the resident.

The DON further stated care plans can change and they need to be updated to ensure that residents get the optimum care.

During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/25/2024, the P&P indicated a comprehensive, person-centered care plan: a.

Includes measurable objectives and timeframes; b.

Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:

• Services that would otherwise be provided for the above, but are not provided due to the resident

exercising his or her rights, including the right to refuse treatment;

• Which professional services are responsible for each element of care;

c.

Includes the resident's stated goals upon admission and desired outcomes; d.

Build on the resident's strengths; and e.

Reflects currently recognized standards of practice for problem areas and conditions.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During an interview on 9/5/2024, at 2:48 PM, with the Director of Nursing (DON,) the DON stated that

rotate insulin administration sites to prevent lipodystrophy (thickened skin) to the sites that was frequently administered with insulin.

The DON stated that several licensed nurses failed to rotate the insulin administration sites for Resident 24, 43 and 85 and placed the residents at risk of harm from lipodystrophy.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

well-being of the resident.

Supporting, last reviewed on 7/25/2024, the policy and procedure indicated appropriate care and

consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During an interview with Treatment Nurse 1 (TX 1), on 9/6/2024, at 1:28 p.m., TX 1 stated that she performs the wound treatments for Resident 62. TX 1 stated Resident 62's treatments include placing the resident on a LALM. TX 1 stated when residents are placed on a LALM, the facility uses two layers, which can be an incontinence brief, pad, and/or flat sheet. TX 1 stated when she administered Resident 62's treatment, she observed the resident with a pad and an incontinence brief. TX 1 stated Resident 62's LALM should have a flat sheet covering it because an exposed mattress can potentially cause the resident's skin to stick to the mattress and be a potential cause for additional skin issues.

During an interview with the Director of Nursing (DON), on 9/6/2024, at 2:01 p.m., the DON stated a flat sheet should be placed over a LALM to provide a barrier between the resident and the LALM material to prevent the occurrence of additional skin issues for the resident.

During a review of the facility's policy and procedure (P&P) titled, Pressure-Reducing Mattresses, last reviewed 7/25/2024, the P&P indicated to place a flat sheet over the mattress, while ensuring no more than two layers of linen are between resident and pressure reducing device.

During a review of a facility provided document titled, [Pressure Reducing Mattress (PRM) 2] Operator's Manual, dated 3/15/2016, the document indicated to cover the mattress with a cotton sheet to avoid direct skin contact and improve the resident's comfort level.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 11's History and Physical (H&P) dated 6/13/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/28/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

The MDS indicated Resident 11 had impairment on both upper extremities.

During a review of Resident 11's fall risk assessments 5/31/2024, and 9/5/2024, the fall risk assessments indicated the resident was a high risk for falls.

During a review of Resident 11's care plan (CP) on the resident receiving oxygen therapy due to respiratory failure last revised 8/20/2024 with target date 11/20/2024, the CP indicated to observe for safety when using oxygen as one of the interventions.

During a concurrent observation an interview on 9/3/2024 at 12;22 p.m., inside Resident 11's room with Certified Nursing Assistant 7 (CNA 7), observed the resident's EF pole and oxygen concentrator were partially placed on top of the floor mat. CNA 7 stated the oxygen concentrator and EF pole are not stable and there is a risk of it fall over Resident 11 and cause injury to the resident.

During a concurrent observation and interview on 9/5/2024 at 2:00 p.m., inside Resident 11's room with Registered Nurse 2 (RN 2) and Respiratory Therapist 2 (RT 2), RN 2 and RT 2 verified the oxygen concentrator and EF pole were partially placed on top of the floor mat and were not stable. RN 2 and RT 2 stated no equipment should be placed on top of the floor mat at all times. RN 2 stated the EF pole had the potential to fall over the resident and injure the resident. RT 2 stated the oxygen concentrator had the potential to fall over and pull the tubing that was connected to the re[TRUNCATED]

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During an on 9/3/2024 at 9:50 a.m., inside Resident 55's room, observed resident lying in bed with the EF bottle and water flush bag hanging on the pole at the resident's bedside.

The EF bottle and water flush bag tubing was connected to the resident's G-tube and was delivering the EF via pump with infusion rate at 69 ml/hr and the water flush at 60 ml/hr.

The EF bottle and water flush bag did not indicate the rate of infusion.

During a concurrent observation and interview on 9/3/2024 at 10:40 a.m., inside Resident 55's room with Registered Nurse 2 (RN 2), RN 2 stated the label on Resident 55's EF bottle and water flush bag did not indicate the rate of infusion. RN 2 stated all EF bottle and water flush bag labels should indicate the resident's name, the start date and time, and the infusion rate to ensure the resident was getting the correct amount of EF and water required to meet their needs.

During an interview on 9/6/2024 at 3:00 p.m., with the Director of Nursing (DON), the DON stated all EF bottles and water flush bags are to be changed every 12 p.m. per facility practice.

The DON stated prior to starting a new EF bottle and water flush bag, the licensed nurse should check the physician's order for accuracy and ensure the label indicated the resident's name, room number, the start date and time, and the infusion rate to ensure the resident was getting the correct amount of nutrition and hydration needed.

During a review of the facility's policy and procedure (P&P) titled, Enteral Tube Feeding via Gravity Bag, last reviewed on 7/25/2024, the P&P indicated a purpose to provide nourishment to the resident who is unable to obtain nourishment orally.

The P&P indicated to check the enteral nutrition label against the order before administration.

The P&P indicated, on the formula label document initials, date, and time the formula was hung/administered, rate of administration (ml/hr), and initial that the label was checked against the order.

During a review of the facility's P&P titled, Supplemental Water Via Enteral Pump, last reviewed on 7/25/2024, indicated that supplemental water will be supplied via enteral pump as ordered by the physician to ensure adequate hydration and assist in the prevention of but not limited to dehydration, G-tube clogging, and need to provide bolus flushing.

The P&P indicated that the open system bag will be changed every 24 hours and should label the bag with the date and time, and rate of administration.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility provided product information titled, Curos Disinfecting Cap for Needleless Connectors, undated, the product information indicated to always place a new Curos disinfecting cap on needleless connector after each use.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a concurrent observation and interview with the Minimum Data Set Coordinator (MDSC), on 9/6/2024, at 9:27 a.m., inside Resident 37's room, the MDSC confirmed Resident 37 had pillows placed underneath the right side of his mattress and that the pillows should not be placed there because it can be considered a restraint.

The MDSC stated there have been instances where Resident 37 attempts to roll out of bed and the pillows placed under the mattress help keep him in place.

The MDSC confirmed Resident 37 had quarter bed rails on the left and right side of his bed.

The MDSC reviewed Resident 37's medical record and stated Resident 37 did not have an assessment performed for the use of pillows underneath the mattress and for bed rails.

The MDSC further stated an assessment needs to be performed prior to the use of restraints to check if it is appropriate to use, to see if other less restrictive measures can be utilized, and to check for the safety of the resident.

During an interview with the DON, on 9/6/2024, at 2:01 p.m., the DON stated prior to obtaining a new order for the use of side rails for Resident 37, there was no entrapment risk assessment performed for the resident.

The DON further stated it is important to perform an assessment prior to application of interventions to ensure the interventions were safe and to honor resident's right to refuse treatment if desired.

During a review of the facility's P&P titled, Bed Safety and Bed Rails, last reviewed on 7/25/2024, the P&P indicated before using bed rails for any reason, the staff shall inform the resident or resident representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

The following information will be included in the consent: a.

The assessed medical needs that will be addressed with the use of bed rails; b.

The resident's risk from the use of bed rails and how these will be mitigated; h.

The alternatives that were attempted but failed to meet the resident's needs; and i.

The alternatives that were considered but not attempted and the reasons.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During the same interview, the DON stated that Resident 24 does not have documented behaviors of

DON stated that there should have been an attempt for a GDR for Lexapro 5 mg daily or a documentation in the psychiatry notes indicating a clinical rationale for continuing and what contraindications prevented the GDR.

The DON stated it was important to properly assess the absence of behaviors and consider GDR to ensure Resident 24 was receiving treatment that was optimal for Resident's condition and to maintain their highest level of well-being.

The DON stated the facility failed to document a clinical rational for continuing Lexapro 5 mg daily for Resident 24.

During the same interview, the DON stated because of failing to provide a clinical rationale for continuing Lexapro 5 mg daily without an attempt for GDR and failing to obtain HgA1C level, Resident 24 was placed at risk of continuing unnecessary medications including psychotropic medications that could result in adverse consequences and side effects, negatively impacting the resident's well health and well-being.

The DON stated the DON will now have to review all Hospice orders and coordinate the care with them to ensure resident care plans were implemented as indicated and for the residents to maintain their highest practicable self in the absence of adverse effects.

During a review of the facility's Policy & Procedures (P&P) titled Hospice Program, dated July 2017, the P&P indicated:

• In general, it is the responsibility of the facility to meet the resident's personal care and nursing

needs in coordination with the hospice representative and ensure the level of care provided is appropriately based on the individual resident's needs.

• Coordinated care plans for residents receiving hospice services will include the most recent

hospice plan of care as well as the care and services by our facility .in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

During a review of the facility's P&P titled Adverse consequences and Medication Errors, dated March 2023, the P&P indicated:

• An 'adverse consequence' is defined as an unpleasant symptoms or event that is due to or associated

with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a. adverse drug/medication reaction b. side effect

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0756 4.

a.

Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.

During a review of the facility's P&P titled Medication Therapy, dated April 2007, the P&P indicated: Policy Statement

• Each resident's medication a regiment shall include only those medications necessary to treat

existing conditions and address significant risks.

• All medication orders will be supported by appropriate care processes and practices.

Policy Interpretation and Implementation

• All decisions related to medications shall include appropriate elements of the care process such as:

a.

Adequately detailed assessment c.

Consideration of the clinical relevance of symptoms and abnormal diagnostic test results

• Upon or shortly after admission and periodically thereafter the staff and practitioner (assisted by the

consultant pharmacist) will review and individuals current medication regimen to identify whether a.

There is a clear indication for treating that individual with the medication b.

The dosage is a appropriate

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0756 5.

When a medication is being given in excessive dose, for excessive periods of time, and without adequate monitoring or in the absence of a valid clinical rationale.

During a review of the facility's P&P titled Medication Regimen Review (Monthly Report), dated April 2008, the P&P indicated that The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly.

The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.

Findings and recommendations are reported to the director of nursing and the attending Physician and if appropriate the medical director and/or the administrator.

E 2. If there is potential for serious harm and the attending Physician does not concur or the attending Physician refuses to document explanation for disagreeing the director of nursing or designee contact the medical director.

During a review of the facility's P&P titled Psychotropic Medication Use, dated October 2017, the P&P indicated that A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics, and antidepressants.

The Facility should comply with the State Operations Manual, and all other Applicable Law relating to the use of psychoactive medications, including gradual dose reductions. 5c. GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: ii.

The physician as document and a clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

• Within the first year in which a resident is admitted on a psychotropic medication or after the

prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.

After the first year, a GDR must be attempted annually, unless clinically contraindicated. 9a.

Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility's policy and procedures (P&P) titled Medication Administration, dated October 2017, the P&P indicated If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication or if necessary, contacts the prescriber for clarification.

During a review of the facility's P&P titled Medication Therapy, dated April 2077, the P&P indicated:

• Each resident's medication regiment shall include only those medications necessary to treat

existing conditions and address significant risks.

• Upon or shortly after admission, and periodically thereafter, the staff and practitioner .will review

an individual's current medication regimen, to identify whether: c.

The frequency of administration and duration of use are appropriate.

During a review of the facility's P&P titled Hospice Program, dated July 2017, the P&P indicated:

• In general, it is the responsibility of the facility to meet the resident's personal care and nursing

needs in coordination with the hospice representative and ensure the level of care provided is appropriately based on the individual resident's needs.

• Coordinated care plans for residents receiving hospice services will include the most recent

hospice plan of care as well as the care and services by our facility .in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility's Policy & Procedures (P&P) titled Hospice Program, dated July 2017, the P&P indicated:

• In general, it is the responsibility of the facility to meet the resident's personal care and nursing

needs in coordination with the hospice representative and ensure the level of care provided is appropriately based on the individual resident's needs.

• Coordinated care plans for residents receiving hospice services will include the most recent

hospice plan of care as well as the care and services by our facility .in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

Wrong time

h.

Failure to follow manufacturer instructions and/or accepted professional standards.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

Long-term use of insulin, , can cause lipodystrophy at the site of repeated insulin injections or

sites within the same region to reduce the risk of lipodystrophy.

A review of the facility provided Highlights of Prescribing Information for Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated HUMALOG administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks.

Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.

A review of the facility provided Highlights of Prescribing Information for Lovenox (enoxaparin sodium) injection, for subcutaneous and intravenous use, with initial U.S. approval in 1993, the highlights of prescribing information indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall.

A review of manufacturer's guide for Instructions for use for Regular Insulin, dated 2011, the guide indicated Injection sites should be rotated within the same region.

A review of facility's P&P, titled Vials and Ampules of Injectable Medications, dated [DATE], the P&P indicated that Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal.

F.

Medication in multi-dose vials may be used until the manufacturer's expiration date or 6 months after opening unless otherwise specified.

A review of facility's P&P, titled Medications with Shortened Expiration Dates, [undated], the P&P listed the following: Humulin R - Regular Human Insulin - Stability, In-use, room temperature vial: 31 days.

A review of manufacturer's guide Highlights of Prescribing Information for Metoprolol Succinate Extended Release, with initial U.S. approval in 1992, dated 5/2023, the highlights of Dosage and Administration section indicated Administer once daily.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of facility's P&P, titled Insulin Administration, dated [DATE], the P&P indicated: To provide guidelines for the safe administration of insulin to residents with diabetes.

• Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record

expiration date and time on the vial (follow manufacturer recommendations for expiration after opening).

During a review of facility's P&P, titled Vials and Ampules of Injectable Medications, dated [DATE], the P&P indicated that Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal.

B.

The date opened and the initials of the first person to use the vial are recorded on multi-dose vials.

F.

Medication in multi-dose vials may be used until the manufacturer's expiration date or 6 months after opening unless otherwise specified.

During a review of facility's P&P, titled Medications with Shortened Expiration Dates, [undated], the P&P listed the following: Humulin R - Regular Human Insulin - Stability, In-use, room temperature vial: 31 days.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of facilities' diet manual titled RENAL 80 GRAM PROTEIN, LOW SALT, LOW POTASSIUM, IN COMBINATION WITH CONTROLLED CARBOHYDRATE DIET (CCHO) dated 2020 indicated Description: This diet is used for the diabetic resident with renal insufficiency at the 80-gm level of protein, low salt, and low potassium. It is then combined with CCHO.

During a review of facility's record of in-service training titled Following Spreadsheet dated 7/11/2024, it indicated an instructor provided training to staff regarding following portion control and appropriate scoop based on spreadsheet.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility's P&P titled Maintenance and Plant Operations dated 7/25/2024

plant.

Maintenance of a safe, sanitary environment ensures safety, affords protection, and enhances well-being of the residents, public and staff.

During a review of the facility's P&P titled Ice Machine Cleaning dated 7/25/2024, it indicated theDSS will schedule maintenance staff the cleaning of ice machine (motor) every three to six months, per manufacturer's guidelines.

During a review of Food Code 2017, it indicated 3-307.11 Miscellaneous Sources of Contamination.

Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. e.

During concurrent observation of the disaster water supply besides the laundry room and interview with DS on 9/4/2024 at 10:16 a.m., 1 of 4 shelves was not 6 in. from the ground. DS stated it was important to have the shelves more than 6 in. high from the ground so they could clean the bottom portion of the shelves for infection control.

During a review of the facility's P&P titled Storage of Canned and Dry Goods dated 7/25/2024, the P&P indicated (5) Food and supplies will be stored 12 inches of the floor to prevent contamination and allow thorough cleaning.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During an interview with Dietary Supervisor (DS) on 9/3/2024 at 1:46 p.m., the DS stated she was not sure if the nurse's station had a refrigerator designated to store resident's food.

During an interview with Registered Nurse 3 (RN 3) on 9/4/2024 at 9:50 a.m., RN 3 stated they did not allow storage of resident's food from the outside however its part of the resident's rights to bring food from the outside. RN 3 stated she was not sure about the policy regarding food from the outside source for the residents but did not want the residents to choke hence they checked for resident's diet, diet consistency and allergies and if the family requested for it. RN 3 stated they did not have any refrigerator to store resident's food in the nurse's station however they might have a refrigerator in the kitchen designated for resident's food from the outside. RN 3 stated it was important to refrigerate food as the food would spoil and residents could have diarrhea if they ate the food that was sitting out.

During an interview with the Director of Nursing (DON) on 9/4/2024 at 10:00 a.m., the DON stated they did not have any refrigerator in the nurse's station or in the facility for food from the outside sources for residents.

The DON stated they instructed resident's family and visitors to only bring non-perishable and dry food and if they brought perishable food, it had to be for one meal only.

The DON stated she would ask the family or visitors to come back the next day if they brought more food in the facility.

The DON stated leftovers would be discarded.

The DON stated there would be emotional harm as a potential outcome if they did not accept food from the visitors or family.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a concurrent observation of the dumpster (a large trash metal container designed to be emptied into a truck) area outside of the facility and interview with Dietary Supervisor (DS) on 9/3/2024 at 2:01 a.m., the DS stated there were cups and gloves on the ground around the dumpster area.

The DS stated it was not okay to have trash around the dumpster area due to infection control.

The DS stated maintenance staff is the one cleaning and maintaining the surroundings of the dumpster.

During an interview with Maintenance Supervisor (MS) on 9/4/2024 at 10:18 p.m., the MS stated the Housekeeping Supervisor (HS) was the one in charge of maintaining the dumpster area's cleanliness.

During an interview with HS on 9/4/2024 at 10:19 a.m., the HS stated they cleaned the dumpster area at a random time every day.

The HS stated the trash around the dumpster area was not acceptable.

The HS stated staff throwing the trash could fall and slip out of the trash.

The HS stated there were too many people throwing trashes and it was hard to maintain.

The HS stated it was important to maintain the dumpster area trash free due to infection control.

During a review of the facility's policies and procedures (P&P) titled Waste Control and Disposal dated 7/25/2024, the P&P indicated POLICY.

All waste will be disposed of daily and as needed throughout the day. PROCEDURES (6) Outside garbage bin should be kept closed at all times and surrounding area must be kept clean.

During a review of the facility's P&P titled Maintenance and Plant Operations dated 7/25/2024, the P&P indicated Maintenance activities include: -Providing a functional, sanitary, and comfortable environment. (I) This facility shall properly maintain the exterior of the building, the grounds, and the parking to ensure they are clean, well-kept, and free as possible of environmental pollutants.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 9's History and Physical (H&P) dated 6/13/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 9's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all[TRUNCATED]

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility policy and procedure titled, Infection Prevention and Control Program, last reviewed 7/25/2024, the policy and procedure indicated an infection prevention and control program is established and maintained to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Immunization is a form of primary prevention.

Widespread use of influenza vaccine in the nursing facility is strongly encouraged.

During a review of the facility policy and procedure titled, Influenza Immunization Will be Offered to all Residents Annually, last reviewed 7/25/2024, the policy and procedure indicated each resident will be offered an influenza immunization October 1 through March 31 annually unless the immunization is medically contraindicated, or the resident has already been immunized during this time period.

Before offering the influenza immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization.

The resident or representative will have the opportunity to refuse the immunization.

The medical records of the resident will include documentation that includes: -The resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization, and -The resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of the facility policy and procedure titled, COVID - 19, last reviewed 8/26/2024, the policy and procedure indicated the facility will continue to educate residents, responsible parties, and staff about the benefits of receiving the vaccination and risks of refusals.

The vaccine and boosters will be offered regularly.

The resident has the right to refuse COVID-19 vaccination and refusals will be documented.

Appropriate documentation of the refusal will be kept.

The facility will educate the resident/responsible party regarding the risk versus benefit of refusal.

The facility will continue to educate the resident, responsible party regarding the benefits of COVID-19 vaccination to keep their vaccination up to date unless it is contraindicated or refused by residents.

056159 09/06/2024

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

spaces, and fixtures are kept in operable condition.

During a review of Resident 89's Admission Record, the Admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses including but not limited to acute respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and generalized muscle weakness.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 46's Admission Record, the record indicated the facility admitted the resident on 10/3/2020, and readmitted the resident on 4/23/2024, with diagnoses including quadriplegia (a condition where all four limbs experience paralysis), seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movement, and awareness), and traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain).

During a review of Resident 46's History and Physical (H&P), dated 4/23/2024, the H&P indicated the resident was incapacitated and had muscle weakness with limited movement, and required visit for safety.

During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/14/2024, the MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, the basic tasks people perform to care for themselves and stay healthy).

During a review of Resident 46's Order Summary Report, dated 4/23/2024, the report indicated an order to apply bilateral padded half siderails as seizure precaution to minimize risks of injury.

Informed consent obtained from resident representative (RP) by MD after explanation of risks and benefits, every shift.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 80's Admission Record, the Admission Record indicated the facility admitted the resident on 4/3/2024 and readmitted the resident on 5/10/2024 with diagnoses that included

potential for actual harm (lack of) following nontraumatic intracerebral hemorrhage (a stroke, loss of blood flow to part of the brain which damages brain tissue), gastrostomy (G-tube or GT, a tube placed directly into the stomach to give

During a review of Resident 80's MDS dated [DATE], the MDS indicated the resident was rarely/never able to understand others and was rarely/never able to make himself understood.

The MDS indicated the resident required substantial/maximal assistance from staff for oral hygiene, toileting, bathing, and dressing, personal hygiene, and mobility.

During a review of Resident 80's Physician Orders Summary Report, the report indicated orders for the following:

- Pressure Reducing Mattress (PRM, designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for skin prevention management, dated 6/3/2024.

During a review of Resident 80's Care Plan (CP) titled, Skin integrity impairment secondary to eczema (disease that causes inflammation, redness, and irritation of the skin), initiated 5/10/2024, the CP indicated to keep the resident clean and dry.

During an interview on 9/3/2024 at 2 p.m., Family Member 1 (FM 1) stated Resident 80 had a rash that was not healing.

During an observation on 9/3/2024 at 12:31 p.m., Resident 80 lay in bed, observed the resident lying on a PRM.

Observed there was no flat sheet on the mattress and the resident lay on a small pad placed between his bottom and lower torso and the mattresses plastic covering.

Observed the residents upper back, legs, and arms came into direct contact with the plastic mattress cover.

During a concurrent observation and interview on 9/5/2024 at 9:46 a.m., with Treatment Nurse 1 (TX 1) and Registered Nurse 3 (RN 3), TX 1 stated Resident 80 was being seen by the dermatologist for a rash. TX 1 stated Resident 80 was laying on a PRM without a sheet and his torso did touch the plastic covering of the PRM. TX 1 stated the facility had flat sheets for the PRMs, but the facility did not allow more than two layers on the PRM. TX 1 stated the two layers may include only two of the following: a sheet, an absorbent pad, or an adult brief. TX 1 stated the resident wore an adult brief and was on top of an absorbent pad and they could not add a sheet because it would be a third layer. TX 1 stated she would not like to be on the plastic of the PRM without a sheet because it would not be comfortable. TX 1 stated not having a sheet may not be a homelike environment. RN 3 stated it did not really seem homelike to be directly on the plastic cover without a sheet.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37 was rarely or never understood, was dependent on staff for activities of daily living such as eating, hygiene, toileting, dressing, bathing, and surface-to-surface transfers.

The MDS further indicated bed rails and other types of restraints were not used.

During a review of Resident 37's History and Physical, dated 8/7/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions.

During an observation on 9/3/2024, at 10:07 a.m., inside Resident 37's room, Resident 37 was sleeping in bed, facing towards the resident's left side, towards the wall. Resident 37's bed was placed against the wall, in the far-right corner upon entry into the room, with the head of the bed pointing towards the room window, the foot of the bed pointing toward the doorway, and the left side of the bed against the wall. Resident 37's bed had two quarter rails on the head and foot of the right side of the bed. Resident 37's bed had pillows placed along the right side, under the mattress, and elevated the right side of the bed to slightly below the top of quarter rails.

During an observation on 9/5/2024, at 2:26 p.m., inside Resident 37's room, Resident 37 was sleeping in bed. Resident 37's bed had pillows placed underneath the right side of the mattress, creating an angled incline away from Resident 37's right side.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 24's Medication Administration Record ([MAR] - a record of mediations administered to residents), for September 2024, the MAR indicated Resident 24 was prescribed:

1.

Lorazepam 0.5 mg to give 1 tablet orally every 6 hours as needed for anxiety/restlessness, scheduled PRN.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 24's Medication Administration Record ([MAR] - a record of mediations administered to residents), for September 2024, the MAR indicated Resident 24 was prescribed:

1.

Escitalopram 5 mg to give 1 tablet orally at bedtime for depression, at 9 PM

2.

Lispro to give per sliding scale SQ before meals and at bedtime for high blood sugar, at 6:30 AM, 11:30 AM, 4:30 PM and 9 PM.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

According to the manufacturer's product labeling, opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening or once storage at room temperature began.

During a concurrent interview with LVN 5, LVN 5 stated that the Humulin R insulin multi-dose (containing more than one dose) vial for Resident 85 was open and labeled with a date indicating that use began on [DATE]. LVN 5 stated that most insulin vials expire within 30 days of opening the vial, and that the Humulin R vial for Resident 85 expired on [DATE] and should be removed from the medication cart. LVN 5 stated that Humulin R doses administered to Resident 85 after [DATE] came from that expired vial, and no other vial was opened or used. LVN 5 stated administering expired insulin will not be effective in keeping the blood sugar stable and can harm Resident 85 by causing high or low blood sugar levels, leading to coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. LVN 5 stated the insulin Humulin R vial needs to be immediately replaced with a new one from pharmacy for Resident 85.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

During a review of Resident 61's Admission Record, the Admission Record indicated the facility admitted the resident on [DATE], with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), protein-calorie malnutrition (a nutritional condition that occurs when the body does not get enough protein, energy, and other essential nutrients), and diabetic chronic kidney disease (a condition that occurs when diabetes damages the kidneys over time)

During a review of Resident 61's History and Physical (H&P), dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 61's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others.

The MDS indicated the resident had severely impaired cognitive skills (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was on a high-risk drug class hypoglycemic (a class of medications that lower blood sugar levels) including insulin.

056159

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056159 B.

Wing 09/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607