Focused Care at Sherman

In the surveyor’s words

From the most serious findings on record at Focused Care at Sherman, in the surveyor’s own words.

• Immediate jeopardy, patternF607May 9, 2025

  Based on observation, interview and record review the facility failed to the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for one (Resident #4) of 10 residents reviewed for abuse and neglect. 1.The facility failed to prevent Resident #4 from neglect and possible abuse when she was fearful of Resident #13 and remained in the room when she did not know who the resident was any longer. 2.The facility failed to investigate Resident #4's concerns and allegations. 3. LVN A, LVN B, the ADON and the DON failed to recognize aa possible allegation of abuse/neglect. 4. The facility failed to identify and intervene for Resident #4. 5. […]

• Immediate jeopardy, isolatedF689Jul 9, 2026

  Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and/or hazards as possible for 1 of 6 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 had adequate supervision when she failed to return inside the building following a smoke break on [DATE] at approximately 7:00 p.m. The facility failed to realize Resident #1 was not in the building until approximately 8:30 p.m. Resident #1 was found by the police on [DATE] at 8:47 p.m. deceased . The Resident was found less than 1/2 mile from the facility down a 20 - 30-foot creek embankment, tangled in tree roots and vines. An IJ was identified on [DATE]. […]

• Immediate jeopardy, isolatedF689May 9, 2025

  Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Resident #115 and Resident #61) reviewed for accidents and hazards. 1. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #115 who was at medium risk for eloping from the facility. On 03/24/25, Resident #115 eloped out of the facility and the facility was not aware the resident eloped. Resident #115 was found in his wheelchair at the intersection of the service road off a major highway. The noncompliance was identified as PNC. […]

• Immediate jeopardy, isolatedF689Mar 13, 2025

  Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. […]

• Immediate jeopardy, isolatedF684Feb 25, 2022

  Based on observation, interview and record review the facility failed to identify and provide needed care and services in accordance with professional standards of practice, (Resident #1) of ten residents reviewed for quality of care. The facility failed to recognize when Resident #1 had a significant change in condition to his skin, by conducting accurate skin assessments ([DATE]), and providing showers to resident ([DATE]). Resident #1 went to an outside doctor appointment on [DATE] at 10:15am and was sent from this appointment to the emergency room where he was diagnosed with [CONDITION(S)] (bacterial infection), gangrene (death of tissue) and [CONDITION(S)] ([CONDITION(S)]-resistant staphylococcus aureus) of the right great toe. […]