Sherman Village HCC: Residents Forced to Lie on Plastic - CA
Federal inspectors found Sherman Village HCC systematically stripped sheets from special medical mattresses, forcing vulnerable residents to sleep on bare plastic surfaces while citing a policy that limited bedding layers.
Resident 80 arrived at the facility in May with frontal lobe damage from a stroke that left him unable to communicate or understand others. He required maximum assistance for basic tasks like bathing and toileting. His family member told inspectors on September 3 that he had a rash that wouldn't heal.
When inspectors observed him that same day, they found him lying on a small pad placed between his lower body and the mattress's plastic covering. His upper back, legs, and arms touched the plastic directly. No sheet covered the pressure-reducing mattress designed to prevent skin breakdown.
Treatment Nurse 1 and Registered Nurse 3 accompanied inspectors to his room two days later. The treatment nurse confirmed the resident was seeing a dermatologist for his rash and acknowledged his torso touched the plastic covering.
"I would not like to be on the plastic of the PRM without a sheet because it would not be comfortable," Treatment Nurse 1 told inspectors. She said not having a sheet "may not be a homelike environment."
Registered Nurse 3 agreed. "It did not really seem homelike to be directly on the plastic cover without a sheet."
The facility's own policy required placing a flat sheet over pressure-reducing mattresses while ensuring no more than two layers of bedding separated residents from the therapeutic surface. Staff interpreted this to mean they could provide either a sheet or incontinence protection, but not both.
Treatment Nurse 1 explained the restriction: if a resident wore an adult brief and lay on an absorbent pad, adding a sheet would create a third layer, violating facility policy.
Director of Nursing reviewed the written procedures during the inspection and admitted the contradiction. The facility was "responsible for providing linens for residents," she said, and "it wasn't very homelike to not provide a sheet for the PRM."
She confirmed the policy required placing a flat sheet on pressure-reducing mattresses but acknowledged it wasn't being provided. "When sheets were not provided for Resident 80 there was the potential for emotional distress from not being provided a homelike environment."
Resident 62 faced identical conditions. The 62-year-old man arrived in June with prostate cancer that had spread to his bones. He had a deep tissue injury on his tailbone and required maximum assistance with all daily activities.
Inspectors found him sleeping on a low air loss mattress without a flat sheet on September 3. Two days later, they observed him again, noting his head rested on a pillow placed directly against the mattress surface with no sheet between them.
Certified Nursing Assistant 8, assigned to his care, explained she had changed his bedding that morning and placed him on a pad with an incontinence brief. She confirmed residents on low air loss mattresses could only have two layers, and the brief and pad counted toward that limit.
"If she placed a thin sheet on the LALM, she would have to remove either the incontinence brief or pad," according to her statement to inspectors. She confirmed his arms and legs touched the mattress surface material directly.
Treatment Nurse 1, who performed wound care for the cancer patient, said his low air loss mattress should have a flat sheet covering it "because an exposed mattress does not look homelike." When a resident's environment doesn't look homelike, she said, "there is a potential for residents to feel uncomfortable."
The Director of Nursing acknowledged that failing to provide a homelike environment could make residents "potentially feel uncomfortable."
A third resident, Resident 68, lived with different but equally degrading conditions. The man had suffered a stroke that left him paralyzed on one side and unable to make decisions. He required total assistance with all daily activities and breathed through a surgically created opening in his throat.
Inspectors found a dust-covered electric fan sitting on the overbed table at the foot of his bed. Certified Nursing Assistant 2 confirmed the fan's frame was lined with "strips of gray powder like material" and identified it as dust.
The maintenance supervisor said housekeeping was responsible for keeping furnishings clean. The housekeeping supervisor explained that fans should be cleaned monthly during deep cleaning schedules and as needed when observed dirty. She said keeping fans clean was important for infection control.
But the Director of Nursing acknowledged all staff shared responsibility for maintaining cleanliness in resident rooms because "dust can cause allergies." She said failing to provide a homelike environment "affects the resident's dignity and quality of life."
The facility's homelike environment policy promised residents "a safe, clean, comfortable, and homelike environment" with "clean bed and bath linens" and "a clean, sanitary, and orderly environment."
The same inspection revealed systematic failures with physical restraints affecting five residents. Staff used bed rails, hand mittens, and other devices without proper physician orders or informed consent from residents or their representatives.
Resident 37 had pillows placed underneath his mattress and bed rails without a doctor's order or assessment. Resident 46 was kept behind four raised side rails without proper evaluation for entrapment risks. Resident 79 was confined by bilateral upper and lower side rails without authorization.
Resident 63 was supposed to wear a hand mitten only on his right hand according to physician orders, but staff applied it incorrectly and too tightly. Resident 73 was kept behind bilateral upper half side rails that didn't match his doctor's specific orders.
The restraint violations carried risks of entrapment, physical decline, psychological harm, and death, according to the inspection report.
For Resident 80, the stroke patient with the unhealing rash, the indignity continued beyond his plastic sleeping surface. His family watched him deteriorate in conditions his own nurses admitted they wouldn't tolerate for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Village Hcc from 2024-09-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SHERMAN VILLAGE HCC in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on September 6, 2024.
Resident 80 arrived at the facility in May with frontal lobe damage from a stroke that left him unable to communicate or understand others.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.