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? |
|---|---|---|---|---|
| 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 | 2023-12-06 | 2023-12-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-07 | 2023-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-07 | 2023-07-25 | 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 | 2022-12-05 | 2023-01-13 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-06 | 2022-12-29 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-09 | 2022-08-11 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-20 | 2022-07-29 | 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 | 2022-05-20 | 2022-07-29 | 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 | 2022-05-20 | 2022-07-29 | 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 | 2022-05-20 | 2022-07-29 | 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 | 2022-05-20 | 2022-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-20 | 2022-07-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-20 | 2022-07-29 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-05-20 | 2022-07-29 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-06-08 | 2022-07-08 | 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 | 2022-06-08 | 2022-07-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-08 | 2022-07-08 | 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 | 2022-01-27 | 2022-03-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-27 | 2022-03-04 | Y |
| 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 | 2022-01-27 | 2022-03-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-27 | 2022-03-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-02 | 2022-03-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-29 | 2021-11-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-07 | 2021-11-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-27 | 2021-10-04 | Y |
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-21 | 2019-11-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-21 | 2019-11-12 | N |
| Respond appropriately to all alleged violations. | 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 |
| 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 |
| 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 |
