Sherwood Nursing & Rehabilitation Center, Inc

Based on observation, record review and interviews, the facility failed to ensure proper hand hygiene was performed during perineal care for one (Resident #106) of one resident reviewed. The findings include: Review of Medical Diagnosis revealed Resident #106 to have diagnoses of congestive heart failure, COPD (Chronic Obstructive Pulmonary Disease), and atrial fibrillation [fluttering heart palpitations]. Review of the admission Minimum Data Set with an Assessment Reference Date of 10/31/2025 revealed a Brief Interview of Mental Status score of 06, which indicates severe cognitive impairment. The MDS also indicated Resident #106 was incontinent of bowel, and occasionally incontinent of bladder. During an observation on 12/08/2025 at 1:37 PM, CNA (certified nursing assistant) #16 and CNA #9 assisted Resident #106 into bed and removed Resident #106's pajama bottoms while wearing gloves. CNA #9 folded down the front of Resident 106's brief and wiped the resident's perineal area. Resident #106 assisted in rolling to the right-side and CNA #16 wiped down the buttocks area twice in one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to ensure dented food cans were promptly removed/ discarded; expired food items and spices were promptly removed/discarded on or before the expiration or use by date; food stored in the freezer and dry storage area were dated to ensure first in and first; dietary staff wore hairnets to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchens; serving dishes were stored properly to prevent the potential for cross contamination;1 of 2 ice machines was maintained in clean and sanitary condition and dietary staff handled glassware items properly to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect residents who received meals from 1 of 1 kitchen (total census: 94). The findings are: 1. On 9/9/2024 at 9:43AM, the plate warmer full of plates to be used in portioning food items to be served to the residents for lunch were not covered, exposing them to debris or pests. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure resident rooms were clean, safe, and homelike for 1 (Resident #357) of 1 resident reviewed for homelike environment. Findings include: A review of the facility's undated policy titled ,Housekeeping indicated, Housekeeping services are planned, operated, and maintained to provide a safe and sanitary environment. 1. Housekeeping staff will be skilled in the six basic functions of sweeping, mopping, dusting, cleaning, waxing, and polishing. 2. Housekeeping staff will strive to keep the facility free from offensive odors, accumulation of dirt, rubbish, dust, and safety hazards . 4. Walls and floors shall be cleaned during periods when the least amount of food is exposed, such as between meals. 5. Floors will be cleaned regularly, and any floor polish will have a non-slip finish . 7. Bedpans, commodes, and urinals will be covered after use, emptied promptly, and thoroughly cleaned after use. This may be done by nursing personnel. A review of an admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, facility document review, the facility failed to ensure discharge Minimum Data Set (MDS) was completed and transmitted for 2 (Resident #44 and Resident #93) of 2 residents reviewed for MDS accuracy and timing of assessments. Findings include: 1. On 09/12/2024 at 12:30 PM, the Administrator stated the facility did not have a policy for the MDS and stated that the facility uses the Resident Assessment Instrument (RAI) guidelines. 2. A review of the admission Record indicated the facility admitted Resident #44 on 03/18/2024 with diagnoses that included pulmonary embolism and acute respiratory failure with hypoxia. Resident #44 was discharged from the facility on 04/25/2024. a. The 5-day MDS with an Assessment Reference Date (ARD) of 03/22/2024 revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. 3. A review of the admission Record indicated the facility admitted Resident #93 on 04/05/2024 with diagnoses that included sepsis, acute kidney failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 4 (Resident #301, Resident #351, Resident #352, and Resident #357) of 4 residents reviewed for baseline care plans. Findings include: 1. On 09/12/2024 at 10:00 AM, the Administrator stated the facility did not have a policy for baseline care plans due to it being in the regulations. 2. A review of the admission Record indicated the facility admitted Resident #301 on 04/25/2024 with diagnoses of congestive heart failure, dyspnea(shortness of breath) and fall. a. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2024, revealed Resident #301 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. b. A review of the electronic medical record revealed Resident #301 had no baseline care plan. 3. A review of the admission Record indicated that the facility admitted Resident #351 on 08/16/2024 with diagnoses that included atrioventricular block,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure a dialysis care plan was initiated for 1 (Resident #351) of 1 resident reviewed for dialysis care planning. Findings include: 1. On 09/12/2024 at 10:00 AM, the Administrator stated the facility did not have a policy for care planning due to it being in the regulations. 2. A review of the admission Record, indicated the facility admitted Resident #351 with diagnoses that included heart disease, retention of urine, and end stage renal disease. a. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2024, revealed Resident #351 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Resident #351 was marked on the MDS as receiving hemodialysis. b. A review of Resident #351's Care Plan, initiated on 08/19/2024, revealed the resident had no dialysis care plan with interventions. 3. During an interview with the Director of Nursing (DON) on 09/11/24 at 11:15 AM, verification was received that there was no order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility document review, the facility failed to ensure proper hand hygiene and proper wearing and removal of personal protective equipment for 1 (Resident #355) of 1 resident reviewed for enhanced barrier precautions. Findings include: 1. A review of a facility policy titled, Handwashing/Hand Hygiene, dated 11/16/2016, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 4. Use an alcohol-based hand rub if no visible soiling, 5. Hand hygiene is the final step after removing and disposing of personal protective equipment. A review of the facility's undated policy titled, Isolation Precautions, Categories of, dated 11/22/2016 indicated Gloves and Hand washing:1. Wear gloves (clean, nonsterile) when entering the room. 2. During the course of caring for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure that resident equipment and living space was maintained in a clean, serviceable manner to maintain resident health and dignity for all 91 residents who currently reside in the facility. The findings included: The following observations were made on 09/18/2023. a. At 11:06 AM, the wheelchair of Resident in room [ROOM NUMBER] B had dirt and debris covering the spokes and the metal was covered in food crumbs and dust. b. At 11:21 AM, room [ROOM NUMBER] had multiple areas of dust, lint, and the trash can was overflowing. c. At 11:47 AM in room [ROOM NUMBER] bathroom, a raised toilet chair had dark brown rust on the metal bar which supports the toilet seat. The following observations were made on 09/18/2023 at 11:50 AM in room [ROOM NUMBER]. a. The pole supporting the Resident's tube feeding had what appeared to be dried formula on the metal base. b. The floor around the base of the pole was covered with dried areas of liquid, dirt, dust, and debris.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews the facility failed to ensure that staff sanitized hands between assisting residents with eating during lunch in the main dining room. The facility failed to ensure foods stored in the kitchen freezer were properly sealed to prevent freezer burn and food cans were not damaged to prevent the growth of bacteria. These failed practices had the potential to affect 89 residents who receive meals from the kitchen. The findings included: During observation on 09/18/2023 at 10:55 AM in the kitchen inside the walk-in refrigerator, was 1 box containing an unsealed bag of 7 chicken patties. The Assistant Dietary Manger (ADM) confirmed the chicken patties should be sealed. During observation on 09/18/2023 at 11:03 AM, there were 2 dented cans in the kitchen. During observation on 09/18/2023 at 12:49 PM Nurse Aid (NA) #1 was assisting one female resident with her food, then turned to assist another female resident with her food. There was no handwashing or hand sanitizing observed between assisting the Residents. During observation on 09/18/2023 at 12:50 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure medications were stored safely. The failed practice had the potential to affect 1 Resident (Resident #36) sampled resident. The findings included: Review of Resident #36's medical diagnosis form showed diagnoses of cerebral infarction, dementia, anxiety, and major depression. During observation on 09/18/2023 03:11 PM, Resident #36's bathroom had multiple medicine cups with a clear white cream inside, and one medicine cup with a tan colored powder. Several unlabeled toothbrushes that belonged to Resident #36 and the roommate. A bottle labeled peri wash, and a bottle labeled odor eliminator. During observation on 09/19/2023 12:44 PM, Resident #36's bathroom counter had 3 medicine cups of clear white thick cream and 1 medicine cup with a tan colored powder. A bottle of Peri wash, and a bottle of odor. Eliminator. During observation on 09/20/2023 11:32 AM, Resident #36's bathroom counter had 1medicine cup with a thick white cream inside and 1 medicine cup with a tan powder inside. On Resident ' s bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.