A list of the most recent deficiencies for Sherwood Oaks Post Acute. 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 | 2024-02-01 | 2024-02-12 | Y |
| 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 | 2023-09-01 | 2023-09-15 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-07-24 | 2023-08-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-11 | 2023-07-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-20 | 2023-05-17 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-02-17 | 2023-03-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-17 | 2023-03-07 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-17 | 2023-03-07 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-17 | 2023-03-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-17 | 2023-03-07 | Y |
| 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 | 2023-02-17 | 2023-03-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-06 | 2023-02-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-06 | 2023-02-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2023-01-03 | 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 | 2022-11-17 | 2023-01-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-17 | 2023-01-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-11-17 | 2023-01-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-17 | 2023-01-03 | 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 | 2022-11-17 | 2023-01-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-17 | 2023-01-03 | 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 | 2022-11-17 | 2023-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-17 | 2023-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2023-01-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-17 | 2023-01-03 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-22 | 2022-12-27 | 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 | 2022-11-22 | 2022-12-27 | 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 | 2022-11-22 | 2022-12-27 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-22 | 2022-12-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-13 | 2022-10-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-10-27 | 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 | 2022-08-16 | 2022-09-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-15 | 2022-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-20 | 2022-08-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-20 | 2022-08-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-07-06 | 2022-08-01 | 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 | 2022-05-11 | 2022-05-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-16 | 2022-04-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-15 | 2022-04-19 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-24 | 2022-04-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-24 | 2022-04-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-24 | 2022-04-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-14 | 2022-04-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-14 | 2022-04-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-13 | 2022-04-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-13 | 2022-04-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-13 | 2022-04-01 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-21 | 2022-03-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-21 | 2022-03-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-10 | 2022-03-04 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-07 | 2022-03-04 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-02-03 | 2022-03-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-03 | 2022-03-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-03 | 2022-03-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-28 | 2022-02-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-02 | 2021-12-20 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-10-20 | 2021-11-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-20 | 2021-11-08 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-10-20 | 2021-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-10-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-30 | 2021-10-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-27 | 2021-09-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-27 | 2021-09-10 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-05-22 | 2019-06-11 | 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 | 2019-05-22 | 2019-06-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-22 | 2019-06-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-22 | 2019-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-22 | 2019-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-22 | 2019-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-22 | 2019-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-05 | 2019-05-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-05 | 2019-05-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-04-05 | 2019-05-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-05 | 2019-05-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-05 | 2019-05-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-05 | 2019-05-02 | 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 | 2019-05-02 | 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 | 2019-04-05 | 2019-05-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-05 | 2019-05-02 | 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 | 2019-04-05 | 2019-05-02 | 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 | 2019-04-05 | 2019-05-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-05 | 2019-05-02 | 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 | 2019-04-05 | 2019-05-02 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-04-05 | 2019-05-02 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-04-05 | 2019-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Develop a communication plan. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-23 | 2018-06-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-04-04 | 2018-04-30 | 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 | 2018-04-04 | 2018-04-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-04 | 2018-04-30 | 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 | 2018-04-04 | 2018-04-30 | 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 | 2018-04-04 | 2018-04-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-04 | 2018-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-04 | 2018-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-04 | 2018-04-30 | N |
