Sherman Village Hcc

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