Sherwood Manor Nursing Home

Inspectors wroteBased on observation, record review, interview, facility document and policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure: 1. Staff donned the appropriate personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions (EBP) for 1 (Resident #63) of 3 residents reviewed for tube feedings, 2. Staff sanitized the multiuse glucometer between residents for 2 (Resident #2 and Resident #11) of 4 residents observed during medication administration, and 3. To conduct fit testing for N-95 masks which had the potential to affect all residents who resided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident was provided with privacy while receiving incontinence care for 1 (Resident #63) of 3 residents sampled for feeding tubes.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to provide an accurate Advance Beneficiary Notice of Non-Coverage (ABN), which included the services that may not be covered and the estimated cost of those services for 2 (Resident #18 and Resident #34) of 3 residents reviewed for beneficiary notification.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a wheelchair was maintained in safe operating condition for 1 (Resident #33) of 2 residents reviewed for environment.

Inspectors wroteBased on interview, record review, and CMS (Centers for Medicare and Medicaid) guidelines, the facility failed to ensure current Minimum Data Set (MDS) assessments were accurately coded for 3 (Residents #1, #9, and #29) of 16 sampled residents reviewed for accurate assessments. Specifically, Resident #1 and Resident #29 were incorrectly coded for insulin instead of injections, and Resident #9 was incorrectly coded for antipsychotics and anticonvulsants in the Medications sections of the MDSs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident received nutritional feeding via a percutaneous endoscopic gastrostomy (PEG) tube according to physician's orders for 1 (Resident #63) of 3 residents reviewed for tube feedings.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of manufacturers' instructions, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 3 medication errors out of 31 opportunities affecting 2 (Resident #2 and Resident #11) of 4 residents reviewed during the medication administration task, resulting in a medication error rate of 9.68%.

Inspectors wroteOn 04/01/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #1 from verbal and physical abuse. During breakfast pass on 03/22/25, CNA #1 was involved in a verbal and physical altercation with Resident #1. CNA #1 was in the hallway passing drinks and Resident #1 was also in the hallway. CNA #1 was witnessed to yell, threaten and throw a glass of milk and a 2/3 full gallon of milk at Resident #1. The altercation was witnessed by CMA #1 and LPN #1 who unsuccessfully attempted to intervene and de-escalate the situation. On 04/01/25 at 5:29 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 04/01/25 at 5:49 p.m., the administrator and DON were notified of the immediate jeopardy situation and provided the IJ template. [...]

Inspectors wroteOn 04/01/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure antipsychotic medications were available and residents were provided ordered medications for a serious mental illness. Resident #1 was admitted on [DATE] and had diagnoses which included schizoaffective disorder, bipolar type. The resident was ordered risperidone (an antipsychotic medication) 3mg twice daily and Seroquel (an antipsychotic medication) 25mg every evening. The resident did not receive 12 consecutive doses of risperidone, from the p.m. dose on 03/13/25 through the a.m. dose on 03/19/25. The first dose of risperidone was not administered until 03/19/25 for the p.m. dose. The resident did not receive five consecutive doses of Seroquel from 03/13/25 through 03/17/25. The first dose of Seroquel was not administered until 03/18/25. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for 1 (#1) of 3 sampled residents who were reviewed for labs. The DON identified 71 residents who had orders for labs.

Inspectors wroteOn 09/26/24, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility failing to assess, monitor, and intervene for a resident at risk for pressure ulcer. Resident #1 was admitted on [DATE]. The admission skin assessment documented no skin concerns to the coccyx area. Resident #1 was totally dependent on staff, placing them at increased risk of PU/PI development. The residents record documented a physician's order for weekly skin assessments. No concerns to the coccyx was documented in these assessments. On 09/19/24 the resident's family member noted a foul odor in the room. The resident's brief was removed revealing a wound over the coccyx measuring 11cm x 13cm. The necrotic bed measured 3.5cm x 5cm and 2cm at the deepest point. The physician was notified on 09/24/24 at which time the physician ordered calcium alginate and Medihoney to the wound bed daily. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. ensure chemicals were secured for one (West hall) of three halls observed for storage of chemicals. LPN #1 identified three shower rooms and one nursing supply closet in the facility; b. failed to ensure residents were assessed for the use of bed rails for one (#33) of one sampled residents reviewed for bed rails. The DON identified 32 residents who utilized bed rails and; c. failed to ensure residents were safely smoking for one (#8) of one sampled residents who were reviewed for smoking. The DON identified 28 residents who smoked.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. ensure infection control was maintained during blood glucose monitoring/insulin administration for two (#123 and #8) of two sampled residents observed during blood glucose monitoring. The Roster Matrix identified 16 residents who received insulin; b. ensure infection control was maintained during medication administration for two (#126 and #15) of nine sampled residents observed during medication administration. The DON identified 73 residents who received medications in the facility; c. ensure enhanced barrier precautions were utilized during medication administration via enteral tube for one (#62) of one sampled residents observed during medication administration via enteral tube. The DON identified seven residents who had enteral tubes; d. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was reviewed for one (#21) of one sampled resident reviewed for care plans. The administrator identified 73 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatments provided for non-pressure wounds had been ordered by the physician for one (#4) of two sampled residents who were reviewed for wound care. The DON identified five residents who had non-pressure wounds in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure weights were obtained per the physician's order for one (#8) of three sampled residents who were reviewed for nutrition. The DON identified one resident who was ordered daily weights.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enteral formula was administered as ordered by the physician for one (#53) of one sampled residents who were reviewed for tube feeding. The DON identified seven residents who required enteral feeding.

Inspectors wroteBased on record review and interview, the facility failed to ensure pre and post dialysis assessments were conducted for one (#8) of one sampled residents who were reviewed for dialysis. The DON identified one resident who required dialysis.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess and inspect bed rails to identify any risks of entrapment for one (#33) of one sampled resident reviewed for bedrails. The DON identified 32 residents who utilized bed rails.

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of abuse were reported to all required state agencies within the required time for two, (#1, and #2) of three sampled residents reviewed for abuse allegations. The Administrator identified the facility census to be 67.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure privacy curtains were utilized during personal care for one (#1) of three sampled residents reviewed for privacy. The Administrator identified 67 residents lived in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement a pressure ulcer policy to fully assess and monitor a new pressure wound for one (#1) of three sampled residents reviewed for pressure ulcers. The Wound Care Physician identified the facility had 3 wounds in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to protect resident's personal medical information during medication pass and treatments. The Resident Census and Conditions of Residents form, dated 08/01/23, documented 63 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a physician order was obtained for a catheter for one (#7) of one sampled resident reviewed for catheters. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 63 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. staff changed their gloves and/or performed proper hand hygiene during incontinent care for one (#24) of one sampled resident observed during incontinent care, b. staff changed their gloves and/or performed proper hand hygiene during wound care for one (#164) of one sampled resident observed during wound care, and c. staff did not handle medication with their bare hands during medication pass. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 63 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a feeding tube was treated with dignity for one (#30) of one sampled resident with a tube feeding. The Resident Census and Conditions of Residents form, dated 08/01/23, documented six residents had a feeding tube.

Inspectors wroteBased on observation and interview, the facility failed to ensure the laundry room was kept clean and in good repair. The Resident Census and Conditions of Residents form, dated 08/01/23, documented 63 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan for a new medication for one (#57) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 08/01/23, documented 63 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound care treatments were completed as ordered for one (#164) of one sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form, dated 08/01/23, documented four residents had a pressure ulcer.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a transfer was performed safely for one (#24) of four sampled residents reviewed for accidents. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 63 residents resided in the facility. The DON identified two residents who utilized a sit to stand lift for transfers.

Inspectors wroteBased on record review and interview, the facility failed to assess a resident for an infection using standardized tools and criteria for the initiation of an antibiotic for one (#19) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/01/23, documented four residents who received antibiotics.