Cycle 1
Health 2025-04-13 · Fire 2025-04-13
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Sherman Oaks, CA
Sherman Oaks Hospital SNF Dp
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4929 Van Nuys Blvd, Sherman Oaks, CA
(818) 907-4540
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
22
Certified beds
Average residents
20
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prime Healthcare
Operator or chain grouping
Approved since
2014-05-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.44
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.70
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
8.72
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
5.03
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
7.86
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
2.09
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
3.22
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
3%
Annual nurse turnover · state 38% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.59% |
8.2%
1.4 pts better
|
Numerator 7 · Denominator 73 |
| Staff flu vaccination coverage | 67.21% |
42%
25.2 pts better
|
Numerator 82 · Denominator 122 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
4.1%
2.6 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 10.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
13.7%
3 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
14.2%
8.2 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
1.0%
2 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.2%
0.1 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.0% |
10.9%
10.9 pts better
|
19.8%
19.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 14.9% |
4.7%
10.2 pts worse
|
5.1%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 15.7% · 4Q avg 14.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-04-02 · Fire 2023-04-02
9 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-15
E · Potential for more than minimal harm
2024-04-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-15
C · Minimal harm
2024-04-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-02
F · Potential for more than minimal harm
2023-04-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-02
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-02
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-02
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-05-05
C · Minimal harm
2023-04-02
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-05
C · Minimal harm
2023-04-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-04-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-04-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-13
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-05-12
F · Potential for more than minimal harm
2024-04-18
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-04-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-04-02
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-04-02
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-04-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-25
Penalties and ownership
What sits behind the stars
Ownership
Aleman, Steven
Corporate Officer · Individual
Bhatia, Sundeep
Operational/Managerial Control · Individual
Bhatia, Sundeep
Corporate Director · Individual
Doan, Christopher
Operational/Managerial Control · Individual
Doan, Christopher
Corporate Officer · Individual
Garcia, Em
Operational/Managerial Control · Individual
Garcia, Em
Corporate Director · Individual
Garcia, Em
Corporate Officer · Individual
Prime Healthcare Foundation Inc
5% Or Greater Direct Ownership Interest · Organization
Prime Healthcare Services - Sherman Oaks, LLC
5% Or Greater Direct Ownership Interest · Organization
Prime Healthcare Services - Sherman Oaks, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Sherman Oaks Health & Rehab
Sherman Oaks, CA
1-star overall rating with 1-star inspections with 43 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Sherman Village Hcc
North Hollywood, CA
1-star overall rating with 1-star inspections with $233,340 in total fines with 38 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Encino Hospital Medical Center D/P SNF
Encino, CA
3-star overall rating with 3-star inspections with $24,030 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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