Sherman Village HCC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 1, 2025

  Based on interview and record review, the facility failed to: 1. Provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of one sampled resident (Resident 97), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), unable to verbalize needs due to aphasia (a disorder that makes it difficult to speak), had history of falls and elopement (the act of leaving a facility unsupervised and without prior authorization), and identified as at risk for elopement, by: A. Failing to monitor Resident 97's whereabouts on 7/25/2025 at 12:14 p.m. (date and time of Resident 97's elopement). […]

• Immediate jeopardy, isolatedF684Aug 22, 2023

  Based on interview and record review, the facility failed to provide care and treatment for one of five sampled residents (Resident 1), who was dependent on staff for care, was at risk of bleeding and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), received treatment and care in accordance with the comprehensive plan of care and professional standards of practice to meet the… […]

• Immediate jeopardy, isolatedF690Aug 22, 2023

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination), was accurately and continuously monitored for signs (objective findings that can be seen or measured) and symptoms (subjective data that can be perceived only by the person affected) of UTI (such as complaints of pain, burning sensation, increase in frequency and urgency during urination, increased temperature, or change in urine character [color, odor, amount, and clarity]) to prevent complications (such as repeated UTIs [two or more UTIs within… […]

• Immediate jeopardy, isolatedF725Aug 22, 2023

  Based on interview and record review, the facility failed to have sufficient and competent nursing staff to provide one of five sampled residents (Resident 1) the necessary nursing care based on the resident's comprehensive plan of care. For Resident 1, who was dependent on staff for care, and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the urinary bladder, a sac that holds urine for temporary storage, to the outside of the body) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), bleeding, and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), the facility failed to ensure: 1. […]

• Actual harm, isolatedF689Nov 28, 2022

  Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices to prevent accident and injury for one of four sampled residents (Resident 1), who was assessed as high fall risk and had history of falls. The facility failed to ensure the tab alarm (a safety device consisting of a pull-string that attaches magnetically to the alarm [placed on the bed or the wheelchair] and to the resident with a garment clip; it alerts the staff when movement [attempting to get up without assistance] is detected while the resident is in bed and chair; staff in the area could respond immediately and may prevent falls) was in use as ordered by the physician. […]