Deficiency Records for Sherwood Oaks Post Acute Care, LLC
Updated as of August 01, 2021
This is not the most recent data for Sherwood Oaks Post Acute Care, LLC. For the most recent information, click here.
A list of the most recent deficiencies for Sherwood Oaks Post Acute Care, LLC. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-13 | 2021-05-13 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-10-26 | 2021-02-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-03-18 | 2021-01-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-15 | 2020-08-17 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-09-21 | 2019-11-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-21 | 2019-11-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-09-21 | 2019-11-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-21 | 2019-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-21 | 2019-11-12 | 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 | 2019-09-21 | 2019-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-21 | 2019-11-12 | N |
| Keep all essential equipment working safely. | Health | 2019-09-21 | 2019-11-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-21 | 2019-11-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-21 | 2019-11-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-21 | 2019-11-12 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-05 | 2019-05-14 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-09-24 | 2018-11-29 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-09-24 | 2018-11-29 | 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 | 2018-09-24 | 2018-11-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-24 | 2018-11-29 | 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 | 2018-09-24 | 2018-11-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-09-24 | 2018-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-24 | 2018-11-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-09-24 | 2018-11-29 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-09-24 | 2018-11-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-24 | 2018-11-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-09-24 | 2018-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-24 | 2018-11-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-24 | 2018-11-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-09-24 | 2018-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-24 | 2018-11-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-09-24 | 2018-11-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Use approved construction type or materials. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-11-06 | 2018-11-21 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-08-07 | 2017-09-22 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-08-07 | 2017-09-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-08-07 | 2017-09-22 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-08-07 | 2017-09-22 | N |
| Offer other nutritional food to each resident who will not eat the food served. | Health | 2017-08-07 | 2017-09-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-07 | 2017-09-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-07 | 2017-09-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-07 | 2017-09-22 | N |
| Keep all essential equipment working safely. | Health | 2017-08-07 | 2017-09-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-08-07 | 2017-09-22 | N |
| Use approved construction type or materials. | Fire Safety | 2017-08-22 | 2017-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-22 | 2017-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-22 | 2017-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-22 | 2017-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-22 | 2017-09-12 | N |
