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? |
|---|---|---|---|---|
| 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 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-04 | 2021-08-13 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-14 | 2021-07-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-08 | 2021-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-27 | 2021-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-27 | 2021-04-05 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-03-27 | 2021-04-05 | Y |
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-27 | 2018-06-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-05-27 | 2018-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-27 | 2018-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-27 | 2018-06-21 | 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 | 2018-05-27 | 2018-06-21 | 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 | 2018-05-27 | 2018-06-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-05-27 | 2018-06-21 | 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 | 2018-05-27 | 2018-06-21 | N |
| Dispose of garbage and refuse properly. | Health | 2018-05-27 | 2018-06-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-27 | 2018-06-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-05-27 | 2018-06-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-26 | 2018-06-21 | N |
