Sherwood Manor Nursing Home

In the surveyor’s words

From the most serious findings on record at Sherwood Manor Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 4, 2025

  On 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. […]

• Immediate jeopardy, isolatedF740Apr 4, 2025

  On 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. […]

• Immediate jeopardy, isolatedF686Sep 27, 2024

  On 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. […]

• No harm, potential for more than minimal, widespreadF880Jul 9, 2026

  Based 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. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions, copyrighted 2001, revealed, 2. […]

• No harm, potential for more than minimal, patternF689Sep 6, 2024

  Based 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. […]