Sherwood Oaks

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 13, 2025

  Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of seven residents (Resident R1) identified as having a high risk for wandering. Findings include: Review of the facility policy Skilled Nursing-Elopement and Wandering Policy dated 2/7/25, indicated this community ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered… […]

• No harm, potential for more than minimal, patternF761Mar 5, 2025

  Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medications carts (West cart, Founder Cart, and Lake Cart). Findings include: Review of the facility policy Disposition of Medications dated 2/7/25, indicated medications that are no longer required for example, expired medications should be dispositioned as indicated. Observation on 3/4/25, at 8:14 a.m., the [NAME] medication cart revealed the following medication stored improperly: -Ipratropium/albuterol (an inhaled medication to breathe easier) with a multi-dose foil package opened and without a date. […]

• No harm, potential for more than minimal, patternF725Dec 5, 2024

  Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six of eight residents (Residents R2, R4, R5, R6, R7 and R8). Findings Include: Review of the facility policy Call Lights last reviewed 2/21/24, indicates all residents have a call light or alternative communication device within their reach at all times when unattended. Facility personnel will answer a call light as soon as possible. To ensure safety and communication between staff and residents in order to timely meet their needs. […]

• No harm, potential for more than minimal, patternF623Sep 25, 2024

  Based on review of clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of three residents (Residents R1, R2, and R3). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/21/24, indicated diagnoses of hypertension, anemia (too little iron in the body causing fatigue), and atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls). […]

• No harm, potential for more than minimal, patternF600Apr 25, 2024

  Based on review of facility policies, documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for four of six residents reviewed (Resident R2, R134, R135 and R9). Findings include: The facility's policy Abuse Neglect, and Exploitation Policy dated 2/21/24, with a previous review date of 4/4/23, indicated it is the facility's policy to provide a safe environment where residents are protected from all forms of abuse and strive to achieve a culture that treats every resident with dignity and respect while providing person centered care and services. The facility goal is to prevent and prohibit all types of abuse, neglect, misappropriation of property and exploitation. […]