Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sherwood Oaks during CMS and state inspections, most recent first.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene: An RN and the DON failed to use EBP during a resident transfer and failed to follow hand hygiene procedures during a wound dressing change for a resident with a left heel wound, hypertension, muscle wasting and atrophy, and Parkinson's Disease. The RN did not complete handwashing for the required time and did not use a clean, dry paper towel to turn off the faucet on some occasions, and both staff confirmed the failures during interview.
A resident with severe cognitive impairment and a history of wandering was able to leave the unit unsupervised after staff failed to maintain adequate supervision and the wander guard system was improperly disabled. Staff did not update the care plan in a timely manner to reflect the resident's increased elopement risk, and multiple staff were unaware of the resident's whereabouts during the incident, resulting in an elopement event.
The NHA and DON did not ensure proper supervision for a resident at high risk for elopement, resulting in the resident leaving the facility and creating an immediate jeopardy situation. Review of job descriptions, records, and staff interviews confirmed that required management and oversight were not provided, leading to noncompliance with professional standards and facility policies.
The facility did not comply with NFPA 101 requirements for self-closing doors, as observed in the basement library where a door was missing a closure arm. This was confirmed by the maintenance supervisor.
The facility was found to have deficiencies in smoke barrier doors on one of its building levels. Observations revealed large gaps in the doors next to the administration office and room 430, allowing air flow and compromising their effectiveness. The maintenance supervisor confirmed these deficiencies during the survey.
A facility was found to have an alcohol-based hand rub (ABHR) dispenser improperly mounted above an ignition source in a resident room, violating NFPA 101 safety standards. This deficiency was confirmed by the maintenance supervisor during a survey.
The facility failed to properly store medications in three of four medication carts, with opened multi-dose packages of Ipratropium/albuterol and Xdemvy eye drops found without dates. This was confirmed by nursing staff and the Director of Nursing, indicating a breach in the facility's medication disposition policy.
Sherwood Oaks failed to develop comprehensive care plans for two residents, omitting critical medical interventions. One resident's care plan did not address the use of a Dexcom G7 Receiver Device for diabetes management, while another's lacked goals for antiplatelet medication use for CVA prophylaxis. These omissions were confirmed by facility staff, indicating non-compliance with federal care planning requirements.
A facility failed to develop comprehensive care plans for two residents and did not follow physician orders for a lab test for a resident on anticoagulant therapy. The missed INR test led to the resident experiencing excessive anticoagulation symptoms, including bruising and nausea, and resulted in a dangerously high INR level. This oversight caused the resident to be sent to the emergency room and later readmitted after suffering a hemorrhagic stroke.
A resident with cognitive impairment and physical dependencies was left unsupervised in the bathroom, resulting in a fall and severe injuries, including a head laceration and a fractured shoulder. The incident highlighted a failure in ensuring proper supervision and assistance, as confirmed by the DON.
The facility failed to provide sufficient nursing staff, resulting in delayed call bell responses for several residents. Grievances and interviews revealed that residents experienced long wait times for assistance, with some instances exceeding 30 minutes. The Director of Nursing acknowledged challenges in meeting response expectations due to staffing shortages and high resident needs.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of three residents, as required. The residents, with various medical conditions, were transferred without the necessary notifications, which was confirmed by the Nursing Home Administrator.
A resident with dementia and recent joint replacement surgery eloped from the facility due to inadequate assessment and supervision. Despite documented confusion and independent ambulation, the resident's care plan was not updated to reflect elopement risk. Additionally, two other residents were not routinely assessed for wandering risk, contrary to facility policy.
The facility failed to ensure resident safety and adherence to care plans, resulting in incidents involving four residents. These included improper transfers and rough handling, indicating a failure to follow care plans and ensure resident safety.
The facility failed to disinfect a pulse oximeter between residents and did not use gloves during eye drop administration, as observed during medication passes for two residents. These actions were confirmed by staff interviews and violated the facility's infection control policies.
The facility failed to maintain the confidentiality of residents' medical information on one of three medication carts. A nurse left a computer screen open with resident information visible to anyone passing by, along with a report sheet and a binder labeled with a resident's name and fluid restrictions.
The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation of a resident. The resident, admitted with multiple diagnoses including heart failure and osteoporosis, suffered a fractured hip after a fall and later had an abrasion and a bruise. The DON confirmed the facility's failure to implement necessary policies.
The facility failed to provide adequate protection from hazards for hot pack use, resulting in a reddened area on a resident's knee that required monitoring until it healed. The incident occurred when a Nurse Aide applied hot packs, contrary to the facility's policy that only nurses should handle hot/cold packs. Interviews and a review of policies confirmed the lapse in adherence to established protocols.
A facility failed to properly secure medications when an RN left a Trelegy Ellipta inhaler unattended on top of a medication cart outside a resident's room, making it accessible to anyone passing by in the hallway.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions and hand hygiene procedures during care for one resident with a left heel wound. The resident was admitted with hypertension, muscle wasting and atrophy, and Parkinson's Disease, and the MDS dated 1/3/26 showed those diagnoses were current. A physician order dated 2/13/26 directed wound care to the left heel, and a physician order dated 2/17/26 directed implementation of Enhanced Barrier Precautions. During an observation on 2/18/26 at 7:40 a.m., the DON and an RN failed to implement Enhanced Barrier Precautions when transferring the resident from a wheelchair to a recliner in the resident's room. During an observation of the resident's wound dressing change at 7:43 a.m., the RN failed to follow proper hand hygiene procedures for seven of seven opportunities, including failing to wash hands for a minimum of 20 seconds and failing on two occasions to turn off faucets with a clean, dry paper towel. During interview at 8:00 a.m., the RN and DON confirmed the failures to follow Enhanced Barrier Precautions during transfers and hand hygiene during the dressing change.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including altered mental status, encephalitis, and unspecified lack of coordination, was assessed as having severe cognitive impairment and required partial to moderate assistance with mobility. Initial elopement risk assessments did not identify wandering behaviors, but subsequent assessments documented wandering, confusion, and exit-seeking behaviors. Despite these findings, the resident's care plan was not updated to reflect the increased risk for wandering and elopement until twenty days after the risk was identified. On the day of the incident, the resident independently left the skilled unit and navigated to another area of the facility without staff knowledge. Multiple staff statements indicated that the resident was seen in various locations prior to the elopement, but staff did not maintain adequate supervision or respond to the resident's movements. The wander guard system, which was intended to prevent such incidents, was disabled by a staff member for another resident without confirming that other at-risk residents were not in the vicinity. As a result, the resident was able to exit the unit undetected, and the alarm did not sound when the resident left the area. Staff interviews and documentation confirmed that the alarm system was not properly monitored and that staff were unaware of the resident's whereabouts during the incident. The failure to provide adequate supervision and to ensure the effectiveness of the wander guard system resulted in the resident's elopement, creating an immediate jeopardy situation. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not meet the required standard of supervision for residents at risk for wandering and elopement.
Failure to Supervise High-Risk Resident Resulting in Elopement and Immediate Jeopardy
Penalty
Summary
The facility failed to ensure effective management and supervision for residents identified as high risk for elopement, resulting in an actual elopement event that created an immediate jeopardy situation. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed their responsibilities to manage the facility and nursing services in accordance with federal, state, and local regulations, and to ensure the highest degree of quality care. However, based on facility and clinical records, as well as staff interviews, it was determined that the NHA and DON did not fulfill these responsibilities, as proper supervision was not provided for residents at high risk for elopement. This failure led to a resident elopement and demonstrated noncompliance with professional standards of practice and facility policies.
Missing Closure Arm on Basement Library Door
Penalty
Summary
The facility failed to meet the requirements for doors with self-closing devices on one of its three building levels. During an observation on March 11, 2025, at 10:01 a.m., it was noted that the basement library door was missing a closure arm. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the absence of the arm from the door closure device.
Plan Of Correction
Work order #192926 added to our computerized work order system to replace door closer for Medical Suite Entrance to one which complies with Life Safety Code 7.2.1.8.2. The device has been replaced and will be monitored every week for 4 weeks and reported in quarterly QAPI meeting.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to meet the smoke barrier requirements on one of its three building levels. During an observation conducted on March 11, 2025, between 11:00 a.m. and 11:24 a.m., it was noted that the smoke barrier doors had large gaps that would allow air flow, compromising their effectiveness. Specifically, the smoke barrier doors next to the administration office and those next to room 430 were identified as having these deficiencies. An interview with the maintenance supervisor at 11:24 a.m. on the same day confirmed the presence of these deficiencies at the time of the survey.
Plan Of Correction
Work order # 192928 added to our computerized work order system to replace the astragals of smoke barrier doors between West and Lake halls on our Skilled Nursing Unit limiting the gap of the doors to 1/8 of an inch or less. The astragal have been replaced and will be monitored monthly for 4 months and reported at our quarterly QAPI meeting.
Improper Placement of ABHR Dispenser
Penalty
Summary
The facility failed to comply with the alcohol-based hand rub dispenser requirements as outlined by NFPA 101. During an observation on March 11, 2025, at 10:40 a.m., it was noted that a resident room, specifically room 440, had an alcohol-based hand rub dispenser mounted above an ignition source. This placement is in violation of the safety standards that prohibit dispensers from being installed within 1 inch of an ignition source. The deficiency was confirmed through an interview with the maintenance supervisor at the time of the survey.
Plan Of Correction
Work order #192927 added to our computerized work order system to address and relocate any/all alcohol-based hand rubbing stations which may be located above any electrical devices throughout the Skilled Nursing Unit. All sanitizing stations have been relocated and will be monitored weekly for 4 weeks and reported at our quarterly QAPI meeting.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to properly store medications in three of four medication carts, specifically the West cart, Founder Cart, and Lake Cart. During an observation, it was noted that the West medication cart contained an opened multi-dose foil package of Ipratropium/albuterol without a date. This was confirmed by RN Employee E2, who acknowledged that the medication should have been dated when opened. Similarly, the Founder's medication cart also had an opened multi-dose foil package of Ipratropium/albuterol without a date, confirmed by LPN Employee E3. Additionally, the Lake medication cart was found to have an opened Xdemvy eye drop container without a date, which was confirmed by RN Employee E4. The Director of Nursing later confirmed that the facility failed to properly store medications in these three medication carts. The facility's policy on the disposition of medications, which requires that expired or no longer required medications be properly dispositioned, was not adhered to, leading to this deficiency.
Plan Of Correction
1. Undated multidose foil package breathing treatments and the eye drops were disposed of on 03/03/2025 and 03/04/2025. 2. Following the findings, the medication carts were audited for other undated multidose foil package breathing treatments or eye drops. None were found. 3. DON/designee educated RNs and LPNs on the need to date multidose foil package breathing treatments and eye drop containers when they are opened. 4. DON/designee will audit med cart three times a week for 2 weeks and weekly thereafter until substantial compliance is achieved. 5. Results of the audits will be reported at the quarterly QA meeting.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
Sherwood Oaks was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically in the development and implementation of comprehensive care plans for residents. The facility's policy mandates that care plans be individualized and reviewed regularly, yet deficiencies were identified for two residents. The care plans failed to address specific medical interventions and goals related to their conditions, as required by federal regulations. Resident R13, admitted with diagnoses including diabetes, high blood pressure, and stroke, did not have a person-centered care plan addressing the use of a Dexcom G7 Receiver Device for continuous glucose monitoring. Despite a physician's order for the device, the care plan lacked goals and interventions related to its use. This oversight was confirmed by the Director of Nursing during an interview, highlighting a gap in the facility's adherence to its own care planning policy. Similarly, Resident R23, with diagnoses of Parkinsonism, chronic pain syndrome, and polyneuropathy, was receiving antiplatelet medication for CVA prophylaxis. However, the care plan did not include goals and interventions related to this medication. The Registered Nurse Assessment Coordinator confirmed this omission, indicating a failure to incorporate critical aspects of the resident's medical treatment into the care plan. These deficiencies demonstrate a lack of comprehensive care planning for residents with complex medical needs.
Plan Of Correction
1. The care plan for R13 and R23 have been updated to include Dexcom use and anti-platelet medication. 2. All resident care plans were evaluated for the need to add interventions related to Dexcom use and anti-platelet medication. No other issues were found. 3. All RNs and LPNs will be educated by the Director of Nursing or designee regarding the need to care plan Dexcom use and anti-platelet medication. 4. The Director of Nursing/designee will audit care plans weekly for one month or until substantial compliance is achieved to ensure residents with Dexcom monitors and anti-platelet medication are addressed on the comprehensive plan of care. 5. Results will be reviewed at the Quarterly QA Meeting.
Failure to Follow Physician Orders Leads to Resident Harm
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as confirmed by the Director of Nursing. Additionally, the facility did not follow physician orders for a lab test for one resident, leading to a significant deficiency. The resident in question, who was admitted with diagnoses including anemia, high blood pressure, and atrial fibrillation, was on a regimen of Coumadin, an anticoagulant medication. The physician had ordered an INR test to be conducted on a specific date to monitor the resident's blood clotting levels, but this test was not transcribed into the electronic health record and was therefore missed. As a result of the missed INR test, the resident experienced symptoms consistent with excessive anticoagulation, including bruising and nausea, and was eventually found to have an extremely high INR level. This led to the resident being sent to the emergency room with a dangerously high INR and subsequently readmitted to the facility after suffering a hemorrhagic stroke. The Director of Nursing confirmed the failure to follow physician orders, which was identified as the root cause of the resident's high INR and subsequent medical complications.
Plan Of Correction
1 - The facility is unable to retroactively correct the INR testing order for 11/24/2024. 2 - The facility reviewed all residents with INR testing orders. No issues were found. 3 - The Director of Nursing/designee will educate RN, LPN, physicians, and CRNP on proper entry of an INR testing order. 4 - The Director of Nursing/designee will audit new orders for INR testing for new orders for meds requiring testing, 5 days a week for 3 weeks, weekly for 3 weeks, then monthly until substantial compliance is achieved. 5 - Results will be reviewed at the Quarterly QA Meeting.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, identified as Resident R6, leading to an accident. Resident R6, who was admitted to the facility in 2017, has a history of muscle weakness, macular degeneration, and allergic rhinitis, and is moderately cognitively impaired with a BIMS score of 12. The resident is dependent on assistance for activities such as toileting, transfers, and bathing, and requires supervision for personal hygiene tasks. On the day of the incident, the resident was left alone in the bathroom to brush her teeth, with the wheelchair's right lock not secured, despite being dependent on assistance for such activities. The incident occurred when the resident was found on the bathroom floor with a laceration on the right side of her head and a skin tear on her left forearm. The resident was not communicating with staff and was later diagnosed with a comminuted proximal humeral fracture. Staff statements indicated that the resident was left alone after being asked if she needed more time, and the bathroom call bell cord was draped around the sink faucet. The Director of Nursing confirmed the facility's failure to provide adequate supervision and assistance, contributing to the resident's fall and subsequent injuries.
Plan Of Correction
Resident R6 was re-evaluated by therapy for her ability to be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. The plan of care has been updated. All residents will be re-evaluated to determine who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. This will be noted in the plan of care as indicated. Nurses, Nursing Assistants, and Therapists will be educated by the Director of Nursing and/or designee on who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. The details will be noted in the plan of care as indicated. Audits will be conducted by observing staff providing care and asking staff how to identify who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. Ten random audits will be completed weekly for 4 weeks or until substantial compliance is achieved. Results will be reviewed at the Quarterly QA meeting.
Insufficient Staffing Leads to Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by extended call bell response times for several residents. The facility's policy requires that all residents have a call light or alternative communication device within reach and that staff respond promptly to call lights. However, multiple grievances and interviews with residents revealed that call bells were not answered in a timely manner, leading to concerns about resident safety and well-being. Resident R2's son reported that his mother experienced delays in call bell responses, which he feared increased her risk of falls. The facility's device activity report confirmed prolonged response times, with some instances exceeding 30 minutes. Resident R4 also reported long wait times for assistance, resulting in accidents, and the device activity report corroborated these claims with several instances of delayed responses. Resident R5 expressed similar concerns, noting that staff shortages contributed to the delays, and the device activity report showed multiple instances of extended wait times. Interviews with other residents and staff further highlighted the issue of insufficient staffing, particularly during busy times such as after 7:00 p.m. The Director of Nursing acknowledged the challenges in meeting call bell response expectations due to competing demands and a high number of residents requiring assistance. Despite the facility's efforts to address these concerns, the report concluded that the facility failed to provide adequate nursing services to ensure the highest practicable well-being of the residents involved.
Plan Of Correction
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. Residents will be educated on the grievance process, expectations for call bell response times, and the opportunity to share their concerns regarding staffing and call bell response times with the facility leadership anonymously, verbally, and/or in writing through resident council meetings. R2, R4, R5, R6, R7, and R8 will be interviewed to determine if improvements have been made. All residents have the potential to be affected by the deficient practice. Education for all nursing staff was completed regarding answering call bell times promptly (with a goal of less than 15 minutes), when rounding. An audit will be conducted by the Director of Nursing/designees on call light response times using the call light report five days a week for two weeks, then 4 times a week for an additional 2 weeks and then 3 times a week for an additional two weeks for a total of 6 weeks. The call bell report will be reviewed by DON/designees to track and trend peak call bell times to improve on timely response to resident needs. Any residents that do not have their call bell answered within the accepted time frame of less than 15 minutes will be interviewed and team members will be educated. At the next resident council meeting, we will discuss call bell response times and if they have improved. The results of these audits will be shared with the administrator and reviewed by the QAPI Committee.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of three residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. The records for three residents, who were transferred to the hospital, lacked documented evidence of written transportation notifications to the Ombudsman. The Nursing Home Administrator confirmed the absence of such notifications during an interview. Resident R1, diagnosed with hypertension, anemia, and atherosclerotic heart disease, was transferred to the hospital and returned to the facility without the required notification. Resident R2, with osteoporosis, obstructive sleep apnea, and dysphagia, was transferred and did not return, also without notification. Similarly, Resident R3, diagnosed with hypertension, arthritis, and a thyroid disorder, was transferred and did not return, with no notification provided. The failure to notify the Ombudsman was acknowledged by the Nursing Home Administrator.
Failure to Identify and Manage Elopement Risk
Penalty
Summary
The facility failed to identify and manage the elopement risk for a resident, leading to an incident where the resident left the skilled nursing unit without supervision. The resident, who had a history of non-Alzheimer's dementia and had undergone joint replacement surgery, was admitted to the facility and initially assessed as not being at risk for wandering or elopement. Despite this assessment, the resident demonstrated behaviors such as self-transferring and ambulating independently, which were documented in nursing progress notes. These behaviors, coupled with cognitive deficits and confusion, were not adequately addressed in the resident's care plan, resulting in the resident eloping from the facility. The incident occurred when the resident was last seen in her room at approximately 3:15 p.m. and was discovered missing at 3:30 p.m. A search was conducted, and the resident was found by security walking near an adjacent building. The resident had left the skilled nursing unit in an attempt to 'feed her fish,' indicating confusion and a lack of understanding of her surroundings. The facility's failure to reassess the resident's elopement risk, despite documented evidence of increased ambulation and confusion, contributed to the incident. Additionally, the facility did not conduct routine Wander Risk Assessments for two other residents, as required by their policy. These assessments are crucial for identifying residents at risk of wandering and ensuring appropriate measures are in place to prevent such incidents. The lack of routine assessments and failure to update care plans for residents with changing conditions highlight deficiencies in the facility's management of elopement risks.
Failure to Ensure Resident Safety and Adherence to Care Plans
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, as evidenced by incidents involving four residents. Resident R2, who required assistance from two staff members for transfers, was transferred by a single Nurse Aide using a pivot disc, resulting in the resident sliding off the bed and being lowered to the floor. Resident R134, who also required assistance from two staff members and a full-body lift for transfers, was transferred by two staff members using a walker, which was not in accordance with the care plan. Resident R134 had a history of falls and fractures, including a fractured right hip after a fall during a transfer. Resident R135, who had dementia and a history of falls, was subjected to rough handling by an LPN who kicked the resident's foot and was verbally rough. Resident R9, who required a sit-to-stand lift and assistance from two staff members for transfers, was transferred by a single Nurse Aide, resulting in the resident being lowered to the floor when their legs began to slide. None of these incidents resulted in injuries, but they indicate a failure to follow care plans and ensure resident safety. The Director of Nursing confirmed that the facility did not ensure residents were free from abuse and neglect for four of the six residents reviewed. The facility's policy aimed to provide a safe environment and prevent all forms of abuse and neglect, but the incidents involving Residents R2, R134, R135, and R9 demonstrate a failure to adhere to these policies. The facility's documentation and staff interviews revealed that the necessary care and services were not consistently provided, leading to these deficiencies.
Infection Control Deficiencies in Equipment Disinfection and Eye Drop Administration
Penalty
Summary
The facility failed to properly disinfect reusable equipment between residents and did not implement infection control practices during the administration of eye drops. Specifically, a registered nurse (RN) used a pulse oximeter on a resident without disinfecting it before placing it back on the medication cart. This was confirmed by the RN during an interview. Additionally, another RN administered eye drops to a resident without wearing gloves, which was also confirmed during an interview. The deficiencies were observed during medication passes for two residents. The facility's policies on cleaning non-critical patient care equipment and medication administration for eye drops were not followed. The policies require proper disinfection of shared equipment and the use of gloves during eye drop administration to prevent the transmission of microorganisms. The failure to adhere to these policies was confirmed through staff interviews and direct observations by the surveyors.
Failure to Maintain Confidentiality of Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of three medication carts. During an observation, a registered nurse left a computer screen open with resident information visible to anyone passing by in the hallway. Additionally, a report sheet with resident information and a binder labeled with a resident's name and fluid restrictions were also visible on the medication cart. This was confirmed by the registered nurse during an interview, indicating a breach of privacy and confidentiality of resident health information.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically for Resident R134. The facility's policy on Abuse, Neglect, Exploitation, last reviewed on 2/21/24, indicated that residents should be protected from all forms of abuse, including injuries of unknown origin, and that such cases should be identified, investigated, and reported to state agencies as required. Resident R134, who was admitted with multiple diagnoses including heart failure, hallucinations, Myelodysplastic disease, heart disease, and osteoporosis, suffered a fractured right hip after a fall during a transfer. A subsequent skin assessment revealed an abrasion on the left hip and a dark purple bruise on the right lateral back. The Director of Nursing confirmed that the facility did not implement the necessary policies and procedures to prevent abuse, neglect, and exploitation for Resident R134.
Failure to Provide Adequate Protection from Hot Pack Hazards
Penalty
Summary
The facility failed to provide adequate protection from hazards for hot pack use for one of five residents, resulting in a reddened area that required monitoring until it healed 8 days later. Resident R18, who had a history of repeated falls and bilateral primary osteoarthritis of the knees, had a care plan that included the application of hot/cold packs to her knees. On the evening of the incident, a Nurse Aide (NA) placed hot packs on Resident R18's knees, which led to the development of a 3.5 cm x 2 cm area of erythema on her right knee. The hot packs were applied again later that night, contrary to the facility's policy that only nurses should handle hot/cold packs. The erythema was assessed by a Registered Nurse (RN) and treated with Calazime barrier cream, and later monitored until it healed. Interviews with multiple Nurse Aides confirmed that they were aware that only nurses were permitted to place and remove hot/cold packs. The Director of Nursing (DON) also confirmed the facility's failure to provide adequate protection from hazards related to hot pack use. The facility's policies on accidents and incidents, as well as the use of heated compresses, were reviewed and indicated that a safe environment should be promoted for all residents. Despite this, the incident occurred, highlighting a lapse in adherence to the established protocols.
Failure to Properly Secure Medications
Penalty
Summary
The facility failed to properly secure medications in one of three medication carts. During an observation, a Registered Nurse (RN) was seen administering medications to a resident and left a Trelegy Ellipta inhaler on top of the medication cart unattended while returning to the resident's room to complete the medication administration. The medication cart was placed outside the resident's room, making the inhaler accessible to anyone passing by in the hallway. The RN confirmed that the medication was left unattended and not properly secured.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,158 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cranberry Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cranberry Place | 1.7 mi | ★★★★★ | 46 | 0 |
| Harmony Hills Healthcare And Rehabilitation Center | 5.3 mi | ★★★★★ | 1 | 0 |
| St John Specialty Care Center | 5.5 mi | ★★★★★ | 4 | 0 |
| Passavant Retirement And Healt | 6.2 mi | ★★★★★ | 20 | 0 |
| Kadima Rehabilitation & Nursing At Harmony | 7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sherwood Oaks.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.