Sherwood Healthcare Center

In the surveyor’s words

From the most serious findings on record at Sherwood Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 9, 2025

  Based on observation, interview and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Employees were unable to demonstrate the correct concentration for sanitation solution, 2. Several pots, pans, bowls, and trays were found stacked wet (in ready to use areas), 3. Two frying pans were found darkened, stained, and scratched, 4. Three ladles, two saucepans, and a colander were found stored with a white film covering the food contact surfaces, 5. Two sandwiches stored in the refrigerator had missing information on label, and an opened gelatin container lacked any labeling, 6. Broken, chipped tiles and missing paint found on floor of kitchen and storeroom, 7. […]

• No harm, potential for more than minimal, patternF658May 9, 2025

  Based on interview and record review, the facility failed to ensure professional standards of care were followed for three of 23 sampled residents (Resident 3, Resident 31, and Resident 45), for a census of 54, when: 1. Resident 3's weight change was not reported to the physician as ordered; 2. Resident 45's weight changes were not reported to the physician as ordered; 3. Resident 31's arm circumference and catheter length were not recorded during midline catheter (a thin, soft tube placed into a large vein in the upper arm) dressing change as ordered; 4. Resident 31's Midodrine (medication used to treat low blood pressure) doses were administered outside the blood pressure parameters; and, 5. […]

• No harm, potential for more than minimal, patternF804May 9, 2025

  Based on observation, interview and record review food was not prepared by methods that conserve nutritive value, flavor, and appearance when 1) recipes were not followed, and 2) hot food was not consistently provided to residents in the 2nd hall. This failure had the potential to lead to poor intake, nutrient deficiencies, and malnutrition for the 51 residents eating facility-prepared foods. Findings: 1. During a visit to the kitchen on 5/7/25 at 9:30 a.m. Dietary [NAME] (DC) was preparing the lunch meal which consisted of Sweet and Sour Chicken, Sesame Noodles, Stir Fry Vegetables, Mandarin Asian Salad, and a Lemon Snow Bar. Review of facility provided recipe Sweet & Sour Chicken (Healthcare Menus Direct, LLC, 2024) was reviewed with DC. […]

• No harm, potential for more than minimal, patternF806May 9, 2025

  Based on observation, interview, and record review, the alternative food options provided to residents who choose the peanut butter and jelly (PB&J), or grilled cheese sandwiches were not of similar nutritive value to the main entree. This failure had the possibility of leading to malnutrition and weight loss. Findings: During a visit to the kitchen during lunch meal plating on 5/8/25 at 11:25 a.m., a grilled cheese sandwich was prepared and left on the grill. Dietary [NAME] (DC) stated it was for a resident who had ordered the sandwich for lunch instead of the main meal. […]

• No harm, potential for more than minimal, patternF813May 9, 2025

  Based on observation, interview and record review, the facility lacked a dedicated refrigerator for storing food brought for residents by family or visitors. This failure had the potential to limit food intake due to the inability to store preferred foods. Findings: During an interview on 5/8/25 at 8:40 a.m. with Certified Nursing Assistant 1 (CNA 1) on Hallway 2, CNA 1 stated that food could be brought in for residents. The food would be checked against the diet order as well as checked for safety before being given to the resident. The residents would have 2 hours to consume it and after that, the food would be considered unsafe and would be discarded. […]