Sherwood Oaks Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF658Jul 20, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff accordingly by professional standard followed and implemented the facility's policy and procedure on elopement by notifying the police when one of two residents (Resident 1) was found missing from the facility on 1/4/22 for more than an hour (7:15 AM to 8:40 AM) and remained missing after search of the facility by staff. This failure contributed to the delay in the search of Resident 1, and when found by a good samaritan (GS) almost a mile away from the facility, the resident already sustained body injuries from a fall by the side of a busy street and was transported to a local hospital. […]

• No harm, potential for more than minimal, widespreadF575Feb 6, 2025

  Based 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. Findings included: A facility policy titled, Federal Posting Policy, version 05/2024, revealed, This policy ensures compliance with federal posting requirements for skilled nursing facilities. The facility will prominently display all federally mandated notices to inform employees, residents, and visitors of their rights and protections under federal law. This policy applies to all required postings in publicly accessible areas of the facility. The policy revealed that 1. […]

• No harm, potential for more than minimal, widespreadF563Jan 21, 2022

  Based on observation, interview, and record review, the facility failed to allow visitation when staff limited the number of visitors. This facility failure had the potential to cause residents' emotional distress. Findings: Review of the facility policy titled, Revised Visitation Policy, revised 8/13/21, indicated in part . Facility shall allow indoor in-room visitation for: All residents, including unvaccinated, partially vaccinated, and fully vaccinated residents. During an interview and concurrent observation with receptionist (R 1) on 12/2/21, at 4:45 p.m., R 1 stated We only allow ten visitors per day, this is the log I use. […]

• No harm, potential for more than minimal, patternF804Nov 17, 2022

  Based 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. Findings: During a confidential resident council meeting on 11/15/22, at 2:32 p.m., nine of nine residents present stated they were not satisfied with the temperature of the food when served, specifying the food was not hot enough. […]

• No harm, potential for more than minimal, patternF812Nov 17, 2022

  Based 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. […]