Sherwood Oaks Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free and protected from abuse on one of one resident (Resident 6) per facility's policy and procedure, when an allegation of abuse was reported against a Certified Nurse Aid (CNA4). CNA 4 was not sent home but instead transferred to another area of the facility to continue working with care of other residents. This failure placed residents at risk for potential acts of abuse from the CNA. During an interview, on 6/9/26, at 2 p.m., with the Director of Staff Development (DSD), in the Director of Nursing (DON) office, the DSD stated that an allegation of abuse was reported CNA 2 on 6/8/26, at 12 p.m., involving CNA 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse was reported and investigated by staff on three of three residents (Residents 2,3, and1). This failure placed residents in harm's way, unmonitored abusive action by staff and non-implementation of abuse policy by facility. During a telephone interview conducted on 6/9/26, at 11:15 a.m., with Certified Nurse Aid (CNA 2), CNA 2 stated, while assisting CNA3, who had provided care to Residents 2,3,1, on three occasions, CNA3 was rough. For Resident 2 (CNA 2 could not remember the date of the incident) while CNA 3 was changing the shirt of Resident 2, the resident who was nonverbal cried out in pain. CNA 2 stated, witnessing CNA3 grabbing Resident 2's nape (back of neck) roughly and forcibly thrusted the neck and head forward, while changing the resident's shirt. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled resident's (Resident 100) medications were secure and inaccessible to unauthorized staff and residents. This failure had the potential to cause medication errors, including residents ingesting incorrect medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling practices by not labeling resident food items stored in the resident refrigerator with the resident's name and the date of opening. This deficient practice created a potential risk for foodborne illness due to the inability to determine food ownership and product freshness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice when:Facility staff were unaware a Bilevel Positive Airway Pressure (BiPAP or BPAP - a non-invasive ventilator used to assist breathing by delivering pressurized air through a mask using a higher pressure level for inhalation and a lower pressure level for exhalation, to improve oxygen levels and reduce carbon dioxide) was beeping/alarming (alarm was not audible) and not delivering the prescribed therapeutic effect in one of two residents (Resident 1). Facility did not have an operator manual onsite or readily accessible to refer for troubleshooting guidance for an alarming BiPAP.Oxygen flow rate was not accurately set to administer oxygen as ordered by the physician (MD) in two of three residents (Resident 2 and Resident 3). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were implemented when a nebulizer mask (a medical device worn over the nose and mouth to deliver liquid medication directly into the airways as a fine mist) used for breathing treatments was not stored in a manner to maintain hygiene and prevent contamination in one of three residents (Resident 1). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a shower room was sanitary and in good repair. This failure had the potential to violate Residents rights to receive care in a safe, clean and homelike environment. During a concurrent observation and interview, on 7/31/25, beginning at 12:55 p.m., with the Maintenance Director (MTD 1), a shower room located in hallway four was inspected. In the shower room, the shower doorframe was in a state of disrepair, the wall had broken tiles, the call light cord was broken and had been replaced with plastic bags in lieu of replacing the cord, a bottle of lotion was stored atop a dirty sharps container and a used razer was stored in a plastic cup atop a box of clean gloves. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to adhere to its policy and procedure for foods brought in by family and visitors. This failure had the potential for Residents to consume spoiled food and to experience negative outcomes. During a concurrent observation and interview, on 7/31/25, at 1:21 p.m., with the Infection Preventionist (IP 1), the resident refrigerator was inspected. Inside the resident refrigerator was a unlabeled and undated plastic bag containing a head of lettuce which had partially turned brown and two unlabeled and undated half eaten sandwiches in plastic containers. The IP 1 confirmed the observations and verbalized the resident food items should have been labeled with a resident's name and date. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to post the State Survey Agency contact information and a statement regarding a resident's right to file a complaint with the State Survey Agency. This failure had the potential to affect all 94 residents who resided at the facility.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to report a resident-to-resident abuse allegation to the State Agency within two hours of an incident for 2 (Resident #7 and Resident #39) of 3 residents reviewed for abuse. Specifically, on 01/27/2025, the police responded to the facility after Resident #39 reported that Resident #7 bumped into their wheelchair, then bumped the resident's knee. The facility Social Services Director (SSD) documented that she and the Administrator had a conversation with Resident #7 on 01/30/2025 about harassment of Resident #39; however, there was no documented evidence the facility notified the State Agency of a resident-to-resident abuse allegation until 02/05/2025.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer 1 (Resident #49) of 2 residents reviewed for Pre-admission Screening and Resident Review (PASRR) for a Level II screening when Resident #49 was admitted with a diagnosis of psychosis and depression.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect when Resident 1's custom-built hearing aids was lost and was not replaced timely. This failure increased the potential for Resident 1 to not effectively communicate his needs and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), was free from misappropriation of resident property. This failure had the potential for Resident 1 to be subject to financial abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan and follow physician orders, for one of two sampled residents (Resident 1). These failures had the potential to negatively impact Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide requested medical records in a timely manner, to a resident representative, for one of two sampled residents (Resident 1). This failure had violated Resident 1's rights.

Inspectors wroteBased on record review and interview, the facility failed to follow a care planned intervention to monitor the intake and output of one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experince negative outcomes.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders for catheter care, for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experience negative outcomes including an increased risk for developing urinary tract infection(s).

Inspectors wroteBased on record review and interview, the facility failed to administer Metoprolol (a medication used to treat high blood pressure) per physician orders, for one of two sampled residents (Resident 1). This failure had the potential to result in a medication being withheld, when it should have been administered.

Inspectors wroteBased on record review and interview, the facility failed to provide documentation indicating a care planned intervention for falls was carried out for one of two sampled residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was timely monitoring and skin evaluation on a resident's skin in one of three sampled residents (Resident 1). This failure had the potential for miscommunication in skin care that may result in further decline in Resident 1's skin condition after cast removal on the right lower limb .

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan (a document which provides direction for and communicates to staff the individualized care of the resident) for one of three sampled residents (Resident 1) after a fall incident. This failure had the potential to result in Resident 1's repeat occurrence of falling.

Inspectors wroteBased on observation, and interview, the facility failed to label and discard perishable food items, from the resident refrigerator, per policy and procedure. This facility failure had the potential for residents to experience negative outcomes, including foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to ensure a medication ordered by the physician and care planned as an intervention was implemented for one of two sampled residents (Resident 1). This facility failure had the potential for medications to be missed /administration with no follow up, placing Resident 1 at risk for non medication effectiveness or benefit in addressing the health issue the medication was prescribed for.

Inspectors wroteBased on observation and interview, the facility failed to identify and fix a broken window frame and blind curtain handle, in one of three sampled residents (Resident 3) rooms. This facility failure had the potential for residents not to be provided with a homelike and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at a palatable temperature to ensure residents' satisfaction as stated by 9 of 9 residents during the confidential resident council meeting. There were eight-seven residents receiving food from the facility's kitchen. Failure to serve food at an appetizing temperature to ensure resident's satisfaction could result in poor food intake and unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation when: 1. Staff were not following the facility's dating system for food products to ensure used within the shelf- life guidance for safety and quality. 2. Dishes and foodservice equipment stored as clean had dried debris and a build up of grease and grime. 3. Meatballs were not cooled down safely in accordance with directions located on the Cool Down Log. 4. The food processor was not washed and sanitized between food items during puree food preparation which increased the risk of cross-contact of a potential food allergen. As a result, residents were placed at risk for developing a food borne illness. There were eighty-seven residents receiving food from the facility's kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized care plan, for communication, was developed when the resident was not able to avail fully and effectively the use of a communication board for one of 23 sampled residents (Resident 47). This failure had the potential for Resident 47's communication needs not being met with effects on the overall physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the fall care plan for one of 23 sampled residents (Resident 35), was re-evaluated and revised. This failure had the potential of placing Resident 35 at risk for future falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care rendered were according to professional standards when physician orders (PO) were not implemented : 1. Resident 74's gastro enteral feeding tube (GT - tube in stomach for liquid formula to go thru -for nourishment) water flush as ordered was documented done prior to administration. This failure has the potential for the resident not to received the water flush as ordered . 2. Oxygen administration order was not followed for Resident 74. This failure has the potential for the resident to have episodes of respiratory distress. 3. Topical medications for skin problem was not administered to Resident 60. This failure [NAME] the potential for the resident's skin to be more irritated leading to skin openings or infection. ` 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure policy and procedure (P&P) in documenting all the services was followed when the turning task or schedule as part of the intervention and measures to heal off existing pressure areas (skin opening) was not documented, as completed in one resident (Resident 1). This failure placed the resident at further risk for a non healing skin wound /pressure areas detrimental to the resident's overall well being .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents, (Resident 67), received a dental consult, within the first 90 days of admission. This failure had the potential for possible dental issues to not be assessed and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one cook (Cook 2) was competent on internal cooking temperatures for fish and poultry to ensure food safety. This failure placed the residents at risk for a foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu as planned when: 1. The incorrect food item (rice) and portion size was served to one of 23 sampled residents (Resident 24) when finger foods when possible was listed on her meal tray card. 2. Too large of chicken piece sizes were served to one of 23 sampled residents (Resident 68) who was on a Soft & Bite-Sized diet order. 3. The menu for puree diet was not followed for one of 23 sampled residents (Resident 80) when the cook did not prepare puree tartar sauce as directed on the planned menu. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the therapeutic diet, as ordered by the physician, for one of 23 sampled residents (Resident 23), when Resident 23 was fed a whole banana while on a pureed diet. This failure had the potential for Resident 23 to choke on the solid food.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow and implement safe infection control practices when: 1. No visible signage of transmission-based precautions (alert of precautions to prevent spread of infection) was posted at the door for one resident (Resident 76) on contact isolation. 2. Staff failed to donn (put on) personal protective equipments (PPE- disposable gloves and gown to prevent spread of infection) prior to entering contact isolation room for one resident (Resident 13). 3. Two certified nurse assistants failed to sanitize hands before entering patient rooms. 4. Staff failed to appropriately handle and dispose of soiled bandage. These failures had the potential to cause the spread of infection to a vulnerable elderly and immune compromised population.