Sherwood Oaks Post Acute Care, LLC

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a baseline care plan for one resident (Resident 1) of three sampled residents after Resident 1 was assessed as a high fall risk. This failure contributed to Resident 1's fall out of bed on 7/15/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of thirteen sampled residents (Resident 16) received quality nursing care that was resident-centered, based on a comprehensive assessment, and in accordance with her goals of care, as indicated in her Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when she experienced intermittent constipation (problem passing stool; associated with hardened feces [stool]; generally passing less than three stools per week) from 12/1/25 through 1/3/26, but nursing staff: 1. Did not treat her constipation with PRN (given as needed or requested) medication ordered by her physician; 2. Did not notify her physician when she was constipated despite receiving her regularly scheduled medication for constipation; and 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff possessed required competencies (a combination of skills, knowledge, abilities, and behaviors that an individual needs to perform a job successfully) and certifications (an official document awarded by a professional organization verifying an individual's specific knowledge/skills required for a job) when the acting Dietary Manager (Manager J) was not certified to function in that position and did not have documented competencies of a Dietary Manager located in their employee file. These failures potentially prevented dietary staff from providing nourishing, palatable, and well-balanced diets that meet the daily nutritional and special dietary needs of residents. During an interview on 3/03/2026 at 11 a.m., Manager J stated he had been the Dietary Manager for two years. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 32 when: 1. Enhanced [NAME] Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) were not implemented for three of 15 sampled residents (Resident 4, Resident 29, and Resident 35) with an indwelling medical device. Resident 4 with a central venous catheter (long, flexible tube inserted into a large vein and threaded to the heart for long-term delivery of medication, fluids, blood products, or nutrition), Resident 29 with a urinary catheter (a flexible tube inserted into the bladder used to drain urine), and Resident 35 with a suprapubic catheter (SP, a thin, flexible tube inserted into the bladder through a small abdominal incision used to drain urine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ an Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) from early 10/2026 through 3/06/26, leading to Enhanced [NAME] Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria and other germs resistant to three or more classes of antibiotics, making infections difficult to treat and highly contagious] in nursing homes) not being implemented for residents with indwelling medical devices including central venous catheters (long, flexible tube inserted into a large vein and threaded to the heart for long-term delivery of medication, fluids, blood products, or nutrition), urinary catheters (a flexible tube inserted into the bladder used to drain urine), [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three dryers' lint traps located in the laundry room were cleaned out after two uses per the facility's policy. This failure resulted in dryer lint traps accumulating lint, thereby presenting a potential fire risk and creating a hazardous environment for residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs and biologicals safely for a census of 32 residents when a medication cart and a treatment cart were left unlocked and unattended in the facility's lounge room, accessible to residents. Additionally, a second medication cart was observed locked in a hallway outside residents' rooms, with its keys left unattended on top of the cart. These failures could have resulted in unauthorized access to medications by residents leading to accidental ingestion of medications, risk of injuries, contaminated medications, and theft or misuse of controlled substances by residents and staff. During an observation on 3/04/26 at 7:14 a.m., Licensed Nurse L (LN L) was seen preparing morning medications at medication cart #1, in a lounge area containing a total of two medication carts and a treatment cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a manner to maintain nutritive value and palatability (food that has a pleasant, agreeable taste and is enjoyable to eat ) for four of thirteen sampled residents (Resident 4, Resident 35, Resident 5, and Resident 27), in a census of 34, when vegetables were cooked for approximately one hour and held on a steam table (box-like table where food is kept warm by steam or hot water circulating beneath) for approximately one additional hour. These failures caused Resident 4 and Resident 35 to feel unhappy, Resident 5 to decrease her food intake and potentially lose weight, Resident 27 to experience diarrhea, and potentially decreased the nutritive value and palatability of foods being served, thereby negatively impacting heath status and quality of life for residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility Quality Assurance Performance Improvement/Quality Assessment and Assurance (QAPI/QAA, a program that involves a systematic approach to quality assurance and performance improvement designed to identify areas of improvement and develop strategies to improve the quality of care provided to the residents) program failed to identify system-wide problems to correct quality deficiencies when:Since 10/26 through 3/06/26 (see Cross Reference F880 and F882), the facility had not employed an Infection Prevention Nurse (IPN), responsible for overseeing potential infection risks, safeguarding residents' health, and providing staff education on infection prevention measures,2. [...]

Inspectors wroteBased on interview and document review, the facility failed to comply with its Assurance Performance Improvement (QAPI, the process that will guide the nursing home's efforts in assuring care and services are continually improved upon) program by not having the mandated Infection Preventionist (IP, a licensed nurse responsible for designing, implementing, and managing programs that prevent the spread of infections within health care facilities) preset at the recert quarterly meeting, thereby, not meeting the required membership for the program. This failure could have resulted in the facility's inability to identify critical infection control issues, develop appropriate corrective plans, implement those strategies and monitor their effectiveness, all of which had the potential to negatively impact resident health and overall outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain signed consents for two of two sampled residents (Resident 2 and Resident 4), who were routinely administered psychotropic medications (also called antipsychotic medications used to treat mental health disorders), when:1. Resident 2's Seroquel (medication used to manage behavioral symptoms like agitation, aggression, or hallucinations [false perception of objects or events involving the senses]) dose went from 25 milligrams (mg) to 50 mg in the morning and 75 mg to 100 mg in the evening without Resident 2's consent, and;2. Resident 4 received trazodone (an anti-depressant used off-label for sleeplessness) to treat insomnia prior to her Responsible Party (RP, and individual designated to make certain decisions for a nursing home resident) giving written informed consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for one of six sampled residents (Resident 4), who suffered insomnia (inability to sleep) and was being administered an antipsychotic medication (a medication to treat mental illness and used off-label for insomnia symptoms) which required closed monitoring. These findings had the potential to result in increased physical and psychological symptoms associated with insomnia, and inability to track or monitor possible harmful side effects of antipsychotics. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of six sampled residents (Resident 5) addressing weight refusals within seven days of a resident assessment indicating this issue. This failure could have resulted in the inability for staff to identify underlying reasons for weight refusals, offer alternatives, and mitigate health risks related to weight fluctuations. This oversight could have resulted in missed detection of nutritional decline for Resident 5, potentially leading to significant clinical complications. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor the side effects of a psychotropic medication (a medication that influences brain chemistry to help treat mental health conditions by affecting mood, thoughts, behaviors, and perceptions. These types of medications may be hazardous because they carry a significant risk of severe side effects) for one of six residents (Resident 4) despite recommendations from a pharmacist and a subsequent review by the facility physician. This finding had the potential to result in inability for staff to identify significant side effects of the medication which could have resulted in serious harm for Resident 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a clean and sanitary condition for a census of 31 residents when food debris and dried liquids were present on the floor in food preparation and dishwashing areas, and a dust-covered fan was blowing onto clean utensils. This failure increased the risk of food contamination, pest attraction, and food borne illnesses for the residents of the facility. During an observation of the kitchen on 2/05/26 at 10:29 a.m., dried liquids were noted on the floor in front of the refrigerator. The floor under the refrigerators and the stove and along the baseboards was visibly soiled with food crumbs and dried food debris. The debris extended along the wall-floor seam into multiple areas. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent one of two sampled residents (Resident 3) from an avoidable fall, when Resident 3, assessed as high risk for falls, was found on the floor by the bathroom after she had attempted to transfer and ambulate without one staff assistance and supervision to prevent falls. This failure resulted in Resident 3 sustaining a left femoral neck fracture (left hip fracture) that required surgical repair placing Resident 3 at risk for surgical complications including pain, infection, and decreased mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 placed Resident 1's hand on her genital area without Resident 1's consent. This failure resulted in Resident 1 experiencing emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to provide the Department a written report of the results of an abuse investigation within 5 working days of an incident that involved an abuse allegation of inappropriate touching for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the Department's investigation of abuse allegations which may have led to continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from abuse when Resident 1 hit with her fist Resident 2's thigh while they were seated close to each other. This failure caused pain and potential mental anguish to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged resident abuse immediately when Resident 1 allegedly hit Resident 2 who was sitting near and opposite her. This failure reduced the faciltiy's potential to ensure resident safety.

Inspectors wroteBased upon interview and record review the facility failed to have a dedicated full time Director of Nursing. This failure had the potential to put residents at risk for a multi-faceted role of Director of nursing, charge nurse and MDS (Minimum Data Set, a clinical assessment of the resident's functional capabilities and helps staff identify health problems) coordinator whereby the residents were not given the appropriate oversight by a dedicated Director of Nursing.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure they were electronically submitting Payroll Based Journal (PBJ, a system that facilitate the submission of staffing information) data as required every quarter when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time data that allows skilled nursing facilities (SNFs) the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the first quarter (Q1 1/2024 up to 3/2024).

Inspectors wroteBased on interview and facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.) failed to identify quality deficiencies as evidenced by: 1) One sampled resident (Resident 12) self-administered and stored his medications in his room. 2) lack of management oversight that resulted in missing narcotics. There was no investigation or report made to the appropriate agencies until one of the surveyors discovered this deficient practice. 3) lack of protocol and facility's effort to monitor residents and obtain referral and treatment for residents (Resident 1) that were hard of hearing. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify three instances of abuse, when: 1) One unlicensed staff member withheld food for one resident (unidentified resident) due to the resident's behavior; 2) Staff neglected to change briefs soiled with urine and feces, resulting in skin breakdown (no specific resident was identified) and staff verbally abused a resident (Resident 19), who was one out of one sampled resident. These failures to identify abusive behavior from a staff member toward residents created an environment where residents' rights were violated, and the residents were fearful to report any abusive behaviors from the staff for fear of retaliation.

Inspectors wroteBased on interview and record the facility failed to identify and report three instances of abuse when the Administrator had documented disciplinary actions (1/21/24, 1/22/24 and 2/6/24) for one unlicensed staff (Unlicensed Staff C) and did not notify the Department. These failures to report abusive behavior from unlicensed staff towards residents created an environment where residents' rights were violated, and the residents were fearful to report any negative behaviors from staff due to retaliation.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights) for four Resident's: Residents 85, was discharged to home, and Residents 86, 87 and 88 were transferred to acute facilities. These failures had the potential for Residents (Resident 85, 86, 87 and 88) were not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to an acute care facility out of 36 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. basic care plans (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) were completed timely for one out of four sampled residents (Resident 6). 2. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure oral care was provided regularly and per plan of care for one out of six sampled residents (Resident 31). This failure led to Resident 31 having a thick whitish, yellowish tinged material on her tongue and could put Resident 31 at risk for dental caries, bad breath and infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a significant weight change was reported to the physician and the Registered Dietician (RD) for one out of six sampled residents (Resident 6), when: 1. Resident 6 lost 12.8 pounds (#, a measure of weight) or 7.6 percent (%, a relative value indicating hundredth parts of any quantity) between 4/2023 and 5/2023. 2. Resident 6 gained 17.8# or 11.5 % between 5/2023 and 8/2023. These significant weight changes, if not reported to the physician and RD, could put Resident 6 at risk for increased mortality and subsequent occurrence of adverse health outcomes. A review of Resident 6's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure they were adequately staffed when: A.six out of six sampled residents (Residents 12, 13, 20, 24, 27 and 31) complained the facility was short staffed. B. for the month of 4/2024, the total direct care service hours patient per day (DHPPD, staffing requirement ) was not met for 24 out of 30 days on these dates: 4/1/24, 4/4/24, 4/6/24, 4/7/24, 4/9/24, 4/10/24, 4/11/24, 4/12/24, 4/13/24, 4/14/24, 4/16/24, 4/17/24, 4/118/24, 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24 and the Certified Nursing Assistant (CNA) PPD was not met for 28 out of 30 days on these dates: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff have the specific competencies and skill sets necessary to care for residents' needs when: 1.staff did not know what a Baseline Care Plan (BCP, should be developed within 24 hours of admission and contain the minimum health care information necessary to care for the residents) was, and its completion time frame. 2. staff did not know what a Trauma Informed Care (TIC, an approach care that acknowledges the complete picture of a resident's life situation, past and present, to provide effective health care services with a healing orientation and prevent retraumatization) was. These failures could put residents at risk for unsafe, inadequate, and ineffective care. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure: 1. staffing information was posted in a prominent place readily accessible to residents and visitors, when the nursing staffing information was kept in a binder behind the counter at the nursing station 2. staffing information was accurate and current. 3. staffing information was complete and was not missing information when the nursing home patient per day (NHPPD, the actual nursing hours performed by direct caregivers per patient day) was left blank. These failures resulted in the nurse staffing information being inaccessible to residents and visitors at any given time and the facility not meeting the NHPPD staffing requirement (cross reference F725).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure for one out of eight sampled residents (Resident 12): 1. all his medications were secured in a locked storage area with limited access to authorized personnel consistent with state or federal requirements and professional standards of practice. This failure resulted in unsecured and unsafe storage of all the medications of Resident 12 which was a huge safety risk not only to Resident 12 but also to the other residents at the facility. 2. the facility followed their procedures for ensuring his safety when he was self-administering his medications. This failure put Resident 12 at risk for accessing and ingesting medications that could cause clinically significant adverse consequences, worsening of his symptoms which could also result to serious harm or death.

Inspectors wroteBased on observations and interviews, the facility failed to provide residents with food that was palatable (Palatability may influence food choice as it is proportional to the pleasure someone experiences when eating a particular food. It depends on the sensory properties of the food such as taste, smell, texture, sound, and sight). This failure had the potential to result in nutritional problems if the residents declined to eat the food served by the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that: 1. clean linens were transported from the laundry room to the clean storage areas of the facility by methods that promoted cleanliness and protection from dust and soil, when the linen cart used for the transport was not covered. 2. staff perform hand hygiene (HH, a term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers (an alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth) was being done by staff prior to assisting residents with their meal and staff were offering to the residents HH before and after meals for three out of three sampled residents (Residents 6, 24, and 27) 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate the Level II Preadmission Screening (PASARR) after a positive result for Level I PASARR) for one (1) of eight (8) residents, Resident 17. This failure resulted in a delay of MD's evaluation for mental illness and a delay of care and services needed for Resident 17.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure for one out of six sampled residents (Resident 12): 1.was using his continuous positive airway pressure (CPAP, a breathing therapy device that delivers air to a mask worn over the nose) every night at bedtime and staff was assisting him on putting on his CPAP mask. 2.staff obtained a physician order for the setting of his CPAP machine. 3.staff put on a no smoking signage in his room since he was using a CPAP. These failures could lead to daytime Fatigue (lack of energy), high Blood Pressure, low oxygen levels, increased Blood Sugar, elevated heart rate, headaches, and mood changes.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure for one out of six sampled residents (Resident 1) 1.in gaining access to hearing services by obtaining an audiologist (a specialist in the treatment of hearing disorders) referral. 2. making an appointment to see an audiologist. 3 .Resident 1's hearing aids (HA, a small electronic devices that amplify sound, help improve hearing and speech comprehension in people with hearing loss) were checked for functionality. These failures led to Resident 1's having difficulty in hearing spoken words. These failures put Resident 1 at risk for miscommunication, frustration and difficulty understanding spoken words.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one out of four sampled residents, Resident 23, received Range of Motion (ROM- means the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint is capable of doing. Range of motion of a joint is gauged during passive ROM (assisted) PROM or active ROM (independent) AROM) exercises as ordered by her physician and according to her comprehensive care plan. This failure had the potential to result in the development of new contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) or worsening of contractures to her left and right ankles that could affect her health and well-being.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to employ a Certified Dietary Manager with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, when there was no designated full time Director of Food and Nutrition Services onsite, as required, when the facility's Registered Dietitian was not employed on a full-time basis. This failure had the potential to result in food borne illnesses when no oversight was provided to the dietary staff during food preparation and could affect the health and safety of all residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Registered Dietician (RD) provided comprehensive oversight of the dietary services. Failure to ensure comprehensive oversight by the RD might have resulted in: 1. menus were not followed. Refer to F 803; 2. facility did not follow physician prescribed therapeutic diets. Refer to F 808; and 3. the facility did not store and prepare food in accordance with professional standard. Refer to F 812. This failure also had the potential for systematic failures of nutrition service and impaired quality of life for all 35 residents in the facility and had the potential to cause widespread food-borne illness in a vulnerable population with complex medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. eggs were purchased for resident consumption that were not pasteurized, 2. food was stored past the facility's use by date, 3. food was stored in open packaging, 4. fruits and vegetables stored for use had mold spots, had turned brown, and had gotten soft and squishy, 5. food containers were removed from their external packaging and stored without documentation to show the products expiration date, 6. prepared food was stored and ready for use past the facility's policy, 7. food preparation areas were not cleaned or sanitized between uses, 8. staff did not perform hand hygiene after removing their gloves, 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to ensure resident's abilities to perform Activities of Daily Living did not decline when Restorative Nursing Assistant (RNA) services (RNAs perform range of motion exercises and strengthening exercises) were not provided as ordered for four Residents (Resident 4, Resident 84, Resident 28 and Resident 23). This failure had the potential to result in decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enough staff to meet the needs of residents, when Restorative Nursing Assistant (RNA) services were discontinued and used RNA staff as a Certified Nursing Assistant (CNA). This failure had the potential to result in resident falls, skin breakdown, and residents decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed when; 1. 3 out of 3 recipes were not followed for the lunch meal served on 5/19/22, 2. All Residents were given 2 slices from a 5 inch personal pizza rather than 2 slices from a twelve inch pizza for the dinner meal served on 5/16/22, 3. The wheat roll was omitted from the lunch meal served on 5/16/22, a substitution was not offered, 4. 1 resident on a pureed diet (Resident 8) received the wrong dessert item for 1 lunch meal served on 5/19/22. These failures resulted in altered nutritional content of the menu and put vulnerable residents at risk for imbalanced nutrition, weight loss and worsening of medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician prescribed therapeutic diets when: 1. Mechanical Soft (MS) texture was not followed during the 5/19/22 lunch meal, which increased the risk for choking for residents with chewing or swallowing difficulty; 2. High protein diets were not followed, which had the potential for worsening nutritional status of residents that needed protein dense meals. Failure to follow physician ordered diets had the potential to compromise the medical status for all 23 residents with a therapeutic diet.

Inspectors wroteBased on interview and record review, the facility failed to ensure an active and engaged Quality Assurance and Performance Improvement committee. This failure had the potential to not proactively identify resident care issues and develop a sustainable plan to address the concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge plan for one of one sampled residents (Resident 26) when 1) the facility did not discuss Resident 26's facility-initiated discharge plan with the resident's daughter or obtained the daughter's agreement to care for Resident 26, and 2) the facility-initiated discharge plan to discharge Resident 26 to a location that was not determined by the choice or the best interests of Resident 26. This failure resulted in Resident 26 feeling very upset and had to go through an appeal process.