A list of the most recent deficiencies for Focused Care at Sherman. 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-17 | 2023-06-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-17 | 2023-06-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-05-18 | 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 | 2023-04-17 | 2023-05-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-09 | 2023-03-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-17 | 2023-03-10 | Y |
| 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 | 2022-07-27 | 2022-08-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-08 | 2022-06-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-08 | 2022-06-13 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-02-25 | 2022-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-03-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-19 | 2021-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-19 | 2021-11-22 | 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 | 2021-11-19 | 2021-11-22 | 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 | 2021-11-19 | 2021-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2021-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-11-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-16 | 2021-11-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-16 | 2021-11-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-16 | 2021-11-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-16 | 2021-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-16 | 2021-11-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-23 | 2019-08-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-23 | 2019-08-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-23 | 2019-08-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-23 | 2019-08-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-23 | 2019-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-23 | 2019-08-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-23 | 2019-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-22 | 2019-08-25 | 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 | 2019-08-22 | 2019-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-23 | 2019-08-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-22 | 2019-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-26 | 2018-09-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-07-26 | 2018-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-26 | 2018-09-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-07-26 | 2018-08-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-07-26 | 2018-08-24 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-07-26 | 2018-08-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-26 | 2018-08-24 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-07-26 | 2018-08-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-07-26 | 2018-08-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-26 | 2018-08-17 | N |
| Dispose of garbage and refuse properly. | Health | 2018-07-26 | 2018-08-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Develop a communication plan. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-26 | 2018-07-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-22 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-22 | Not Fixed | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-26 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-26 | Not Fixed | N |
