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Deficiency Records for Sherman Village Hcc
A list of the most recent deficiencies for Sherman Village Hcc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sherman Village Hcc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-06 | 2024-09-23 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-09-06 | 2024-09-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-06 | 2024-09-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-06 | 2024-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-06 | 2024-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-06 | 2024-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-09-06 | 2024-09-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-09-06 | 2024-09-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-06 | 2024-09-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-09-06 | 2024-09-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-09-06 | 2024-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-06 | 2024-09-23 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-09-06 | 2024-09-23 | N |
| Dispose of garbage and refuse properly. | Health | 2024-09-06 | 2024-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-06 | 2024-09-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-06 | 2024-09-23 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-09-06 | 2024-09-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-06 | 2024-09-23 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-09-06 | 2024-09-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-09 | 2024-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-09 | 2024-09-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-27 | 2024-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-27 | 2024-09-09 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-08-27 | 2024-09-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-27 | 2024-09-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-27 | 2024-09-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-27 | 2024-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-27 | 2024-09-09 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-08-06 | 2024-08-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-26 | 2024-08-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-07 | 2024-05-15 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-04-17 | 2024-04-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-11 | 2024-04-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-22 | 2023-09-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-22 | 2023-09-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-22 | 2023-09-14 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-08-22 | 2023-09-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-22 | 2023-09-14 | Y |
| Post nurse staffing information every day. | Health | 2023-08-22 | 2023-09-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-06 | 2023-04-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-27 | 2023-04-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-28 | 2023-01-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-26 | 2022-12-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-26 | 2022-12-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-26 | 2022-12-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-28 | 2022-12-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-28 | 2022-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-28 | 2022-12-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-16 | 2022-10-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-10 | 2022-08-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-03 | 2022-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-03 | 2022-08-12 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-03 | 2022-08-12 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-29 | 2022-07-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-10 | 2022-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-10 | 2022-06-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-17 | 2022-04-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-17 | 2022-04-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-17 | 2022-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-17 | 2022-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-17 | 2022-04-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-17 | 2022-04-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-17 | 2022-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-17 | 2022-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-23 | 2022-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-01-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-16 | 2021-12-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2021-12-28 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-12-16 | 2021-12-28 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-05 | 2019-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-05 | 2019-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-05 | 2019-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-05 | 2019-04-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-04-05 | 2019-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-05 | 2019-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-05 | 2019-04-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-05 | 2019-04-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-05 | 2019-04-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-05 | 2019-04-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-04-05 | 2019-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-05 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-04-26 | N |
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