Sherwood Oaks Post Acute Care, LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Jan 27, 2022

  Based on observation, interview and record review, the facility failed to ensure effective administration of its operations, when the facility: 1) Did not have a licensed Administrator to oversee daily operations (including adequate staffing levels); 2) Did not have a Director of Nursing (DON); and, 3) Did not ensure the the Registered Dietitian (RD) executed her duties, per policy and contracted agreement. These deficiencies contributed to staffing issues, negatively impacted the use of resources (personnel), potentially impaired residents' ability to attain/maintain their highest practicable physical, mental, and psychosocial well-being, and created potential harm for 34 of 34 residents. […]

• Actual harm, isolatedF684Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure one of thirteen sampled residents (Resident 16) received quality nursing care that was resident-centered, based on a comprehensive assessment, and in accordance with her goals of care, as indicated in her Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when she experienced intermittent constipation (problem passing stool; associated with hardened feces [stool]; generally passing less than three stools per week) from 12/1/25 through 1/3/26, but nursing staff: 1. Did not treat her constipation with PRN (given as needed or requested) medication ordered by her physician; 2. […]

• Actual harm, isolatedF689Feb 12, 2025

  Based on interview and record review, the facility failed to prevent one of two sampled residents (Resident 3) from an avoidable fall, when Resident 3, assessed as high risk for falls, was found on the floor by the bathroom after she had attempted to transfer and ambulate without one staff assistance and supervision to prevent falls. This failure resulted in Resident 3 sustaining a left femoral neck fracture (left hip fracture) that required surgical repair placing Resident 3 at risk for surgical complications including pain, infection, and decreased mobility. […]

• Actual harm, isolatedF600Jun 7, 2023

  Based on interviews and record reviews, the facility failed to implement its policies and procedures on abuse and ensure that one of three sampled residents, Resident 1, was free from mental abuse (Mental abuse is the use of threats, verbal insults, and other more subtle tactics to control a person's way of thinking. This form of abuse is especially disturbing because it is tailored to destroy self-esteem and confidence and undermine a personal sense of reality or competence) and mistreatment (a cruel, unkind, or unfair way of treating a person), when the door to Resident 1's room was deliberately closed by Licensed Nurse A, while Resident 1 requested for staff assistance. […]

• No harm, potential for more than minimal, widespreadF801Mar 6, 2026

  Based on interview and record review, the facility failed to ensure dietary staff possessed required competencies (a combination of skills, knowledge, abilities, and behaviors that an individual needs to perform a job successfully) and certifications (an official document awarded by a professional organization verifying an individual's specific knowledge/skills required for a job) when the acting Dietary Manager (Manager J) was not certified to function in that position and did not have documented competencies of a Dietary Manager located in their employee file.These failures potentially prevented dietary staff from providing nourishing, palatable, and well-balanced diets that meet the daily nutritional and special dietary needs of residents.During an interview on 3/03/2026 at 11 a.m.,… […]