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Deficiency Records for Sherman Oaks Health and Rehab
A list of the most recent deficiencies for Sherman Oaks Health and Rehab. 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 Oaks Health and Rehab. 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 | 2024-03-21 | 2024-04-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-21 | 2024-04-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-21 | 2024-04-14 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-03-21 | 2024-04-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-03-21 | 2024-04-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-21 | 2024-04-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-03-21 | 2024-04-14 | N |
| 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 | 2024-03-21 | 2024-04-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-21 | 2024-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-21 | 2024-04-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-21 | 2024-04-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-21 | 2024-04-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-21 | 2024-04-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-03-21 | 2024-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-21 | 2024-04-14 | 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 | 2024-03-21 | 2024-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-21 | 2024-04-14 | N |
| Post nurse staffing information every day. | Health | 2024-03-21 | 2024-04-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-21 | 2024-04-14 | 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 | 2024-03-21 | 2024-04-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-21 | 2024-04-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-21 | 2024-04-14 | 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 | 2024-03-21 | 2024-04-14 | 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 | 2024-03-21 | 2024-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-21 | 2024-04-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-21 | 2024-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-04-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-21 | 2024-04-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-21 | 2024-04-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-26 | 2024-04-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-26 | 2024-04-12 | 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 | 2024-03-26 | 2024-04-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-26 | 2024-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-26 | 2024-04-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-26 | 2024-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-26 | 2024-04-12 | 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 | 2024-03-28 | 2024-04-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-28 | 2024-04-09 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-14 | 2024-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2024-01-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-14 | 2024-01-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-07 | 2023-12-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-01 | 2023-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-03 | 2023-08-16 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-05-15 | 2023-05-31 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-08-31 | 2022-09-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-09-23 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-30 | 2022-04-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-25 | 2022-04-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-25 | 2022-04-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-25 | 2022-04-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-03-25 | 2022-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2022-04-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-25 | 2022-04-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-25 | 2022-04-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-25 | 2022-04-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-25 | 2022-04-14 | 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 | 2022-03-25 | 2022-04-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-03-25 | 2022-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 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 | 2019-05-29 | 2019-06-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-29 | 2019-06-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-05-29 | 2019-06-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-29 | 2019-06-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-29 | 2019-06-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-29 | 2019-06-27 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-05-31 | 2019-06-21 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-05-31 | 2019-06-21 | 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 | 2019-05-31 | 2019-06-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-31 | 2019-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-31 | 2019-06-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-05-31 | 2019-06-21 | N |
| 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 | 2019-05-31 | 2019-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-31 | 2019-06-21 | 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 | 2019-05-31 | 2019-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-31 | 2019-06-21 | 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 | 2019-05-31 | 2019-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-31 | 2019-06-21 | N |
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