Sherman Oaks Health & Rehab: Assessment Delays - CA
The resident, identified in inspection records only as Resident 16, was admitted to the facility on September 20, 2024, with diagnoses that included type II diabetes, major depressive disorder, and high blood pressure. A history and physical from October 1, 2024 noted that the resident had the capacity to understand and make decisions.
The assessment in question was a Minimum Data Set Quarterly Assessment, a standardized tool nursing homes use to track a resident's health status and inform care planning. For Resident 16, the assessment reference date was December 27, 2024, meaning the assessment needed to be completed and submitted no later than January 10, 2025.
It wasn't finished until January 13, 2025. The submission was validated by the federal system on January 15.
Three days late. The MDS nurse confirmed it herself.
During a concurrent interview and record review on March 12, 2025, MDS Nurse 1 reviewed the facility's Final Validation Report, the internal document that records whether an MDS submission was accepted on time. She told inspectors that the report showed the assessment completion date was more than 14 days after the reference date. She confirmed the assessment should have been completed by January 10 and that anything after that date was considered late.
The Director of Nursing, interviewed on March 14, 2025, acknowledged the stakes plainly. She told inspectors that MDS assessments should be completed on time and should reflect the resident's health status at that moment. When they aren't completed on time, she said, there could be a delay in reporting the resident's health status and in reporting quality measures.
That admission came from the facility's own leadership.
The Minimum Data Set is not a formality. For a resident managing type II diabetes, a condition that complicates wound healing and requires careful monitoring of blood sugar, a timely quarterly assessment is the mechanism by which the care team documents current status and flags changes. A late assessment means the snapshot of that resident's health, used to guide nursing decisions and report quality data to federal regulators, was overdue.
Inspectors cited the deficiency under the resident assessments task and classified the level of harm as potential for minimal harm, affecting some residents. The facility's own policy, last reviewed in September 2024, stated that assessment timeframes are based on current requirements. The federal Resident Assessment Instrument manual is explicit: the completion date must fall no later than the assessment reference date plus 14 calendar days.
Resident 16's was not.
Sherman Oaks Health & Rehab is located at 14401 Huston Street in Sherman Oaks. The inspection was completed March 14, 2025.
The Director of Nursing told inspectors what everyone in long-term care already knows: the MDS is how a facility tracks whether a resident's needs are being met. For a resident with diabetes, depression, and high blood pressure, that tracking matters. The three-day gap between what was required and what was done is not large. But it is documented, it is confirmed by the facility's own staff, and it is the kind of administrative failure that, repeated across residents or across quarters, compounds into something harder to explain away.
Nobody at the facility disputed the finding. The MDS nurse read the validation report herself and said it out loud: the assessment was late.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Oaks Health & Rehab from 2025-03-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 10, 2026 · Our methodology
SHERMAN OAKS HEALTH & REHAB in SHERMAN OAKS, CA was cited for violations during a health inspection on March 14, 2025.
A history and physical from October 1, 2024 noted that the resident had the capacity to understand and make decisions.
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.