Sherman Village HCC: Safety Alarm Failures Risk Falls - CA
Federal inspectors found widespread safety failures at Sherman Village HCC during a September inspection, documenting cases where vulnerable residents were left in beds raised as high as 33 inches from the floor and critical safety equipment wasn't functioning properly.
Resident 89, who had severe cognitive impairment and required total assistance with daily activities, was supposed to have a functioning pad alarm to prevent unassisted transfers. The resident had acute respiratory failure, a tracheostomy, and was at high risk for falls.
When Registered Nurse 2 checked the alarm during the inspection, she found it "slightly folded" under the fitted sheets. The alarm didn't sound when Resident 89 moved and turned to the side. Only after disconnecting and reconnecting the device did it begin working properly with a blinking light and audible sound.
"The charge nurses and CNAs are responsible in ensuring the alarms are functioning properly every shift," RN 2 told inspectors. She said alarms should function properly "to ensure resident safety and prevent injuries resulting from falls."
The facility's own policy required checking alarms daily for proper functioning, and manufacturer guidelines warned staff to test the system "each time before leaving the patient unattended" to reduce the risk of serious injury or death.
Beds Left at Dangerous Heights
Three residents were found lying in beds positioned far above the recommended safety height. Resident 25, who had functional quadriplegia and was at high risk for falls, was in a bed measured at 27 inches from the floor. CNA 3 said the bed could be lowered by at least six more inches.
"All resident beds should be kept at its lowest position at all times for their safety, due to the risk of falls when they cough," CNA 3 explained.
Resident 445, who had hemiplegia and seizure disorder, was in a bed raised 32 inches high. Respiratory Therapist 1 was able to lower it by 12 inches and said there was room to go even lower.
The most extreme case involved Resident 60, whose bed was 33 inches from the floor when no care was being provided. When CNA 4 tried to lower it, the bed controls weren't working. He said he would call maintenance to fix the bed.
"The bed should be at its lowest position when not providing care to the resident prevent falls with injuries," CNA 4 stated.
The facility's bed frame manual specifically recommended positioning beds at the lowest height when unattended by caregivers "to minimize the risk of patient injury from falls when getting in and out of the bed." The Director of Nursing told inspectors that the higher the bed, "the greater the risk of the resident sustaining injuries such as fractures or even death."
Equipment Placed on Safety Mats
Inspectors found heavy medical equipment placed directly on fall protection mats, compromising their effectiveness and creating new hazards. In Resident 11's room, both an oxygen concentrator and an IV pole were partially positioned on top of a floor mat designed to cushion falls.
CNA 7 observed that "the oxygen concentrator and EF pole are not stable and there is a risk of it fall over Resident 11 and cause injury to the resident."
When Registered Nurse 2 and Respiratory Therapist 2 examined the setup, they confirmed the equipment was unstable. RN 2 said the IV pole "had the potential to fall over the resident and injure the resident." RT 2 warned the oxygen concentrator "had the potential to fall over and pull the tubing that was connected to the resident."
The Director of Nursing explained that floor mats protect residents from injury during falls or involuntary movements, but placing heavy equipment on them "can cause dent and affect its integrity." She said the bed should have been repositioned to make space for equipment on stable flooring.
Wheelchair Safety Compromised
Resident 19 sat in a wheelchair with two wheels positioned on top of a padded fall mat for about 30 minutes after returning from physical therapy. The resident, who had bone density disorders and muscle weakness, told inspectors she needed assistance to move the wheelchair and had asked staff to relocate the mat, "but they insist that it remained there."
CNA 5 acknowledged the wheels shouldn't be on the fall mat and said rehabilitation staff hadn't notified him the resident had returned to the room.
The Director of Nursing explained that while floor mats prevent injury when residents are in bed, "when the resident is in the WC next to the bed, the floor mat should not be under the wheels of the WC." She warned that wheels on the mat created "a potential that the WC could become unsteady resulting in an accident like a fall."
Broken Flooring Creates Hazard
Resident 42, who had a leg amputation and used a shower chair for toilet transfers, reported hitting his back when the chair became unstable. Inspectors found the shower chair's back wheel positioned on a broken piece of laminate flooring in the bathroom.
The resident explained he used the shower chair "because it is easier for him to make transfers and to use the toilet" due to his amputation. Licensed Vocational Nurse 3 confirmed the flooring was broken and said he reported it to the Maintenance Supervisor on September 3.
But when the Maintenance Supervisor examined the flooring the next day, he said "nobody had reported the flooring issue to him" and confirmed the broken surface "was probably not safe for Resident 42's shower chair to be placed on top of it."
Feeding Tube Safety Lapses
The facility also failed to follow proper protocols for residents with feeding tubes. Inspectors observed Licensed Vocational Nurse 3 connect a feeding tube and start nutrition without checking tube placement first.
LVN 3 acknowledged he should have verified placement to "ensure there is no flow of the feeding into the wrong place." The standard procedure involves using a stethoscope to listen while pushing air through the tube.
Registered Nurse 3 explained that checking placement prevents complications if the tube becomes dislodged, which "could potentially cause an infection in the resident's stomach."
Multiple residents had improperly labeled feeding bottles and water flush bags missing required information about start times, dates, and infusion rates. The Director of Nursing said proper labeling ensures residents receive correct nutrition and prevents them from getting expired formula that could cause gastric problems.
The inspection found violations affecting residents with complex medical conditions including respiratory failure, cognitive impairment, paralysis, and seizure disorders. All the affected residents required total assistance with daily activities and were at high risk for falls.
Sherman Village HCC operates at 12750 Riverside Drive and provides long-term care and rehabilitation services. The facility's policies acknowledged the importance of maintaining safe environments and preventing accidents, but staff repeatedly failed to follow established procedures designed to protect vulnerable residents.
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.
The resident had acute respiratory failure, a tracheostomy, and was at high risk for falls.
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.