Sherwood Manor Nursing Home
2416 West 51stsouth, Tulsa, OK 74107 · Tulsa County · 102 certified beds · avg 66 residents/day · certified since Sep 25, 2013
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 4, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 4, 2025 · F-0740 · triggered by a complaint
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 27, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 28, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (30)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 4, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 4, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint |
| Sep 27, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Sep 6, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 6, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 6, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 6, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 6, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 6, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Sep 6, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Sep 6, 2024 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Jun 25, 2024 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 25, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jun 25, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Aug 3, 2023 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Aug 3, 2023 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 3, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Apr 22, 2021 | E · Potential for harm, repeated | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
| Apr 22, 2021 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 22, 2021 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 22, 2021 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Apr 22, 2021 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Apr 22, 2021 | D · Potential for harm, one-off | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 6 | 0 | E |
| 2023 | 9 | 0 | E |
| 2024 | 12 | 1 | J ▲ |
| 2025 | 3 | 2 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $91,862, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Apr 4, 2025 | Fine | $55,098 |
| Sep 6, 2024 | Fine | $36,764 |
| Sep 6, 2024 | Payment Denial | 2 days from Oct 26, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oklahoma avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.35 | 4.58 | 3.95 | bottom 38% in Oklahoma; top 27% in the U.S. |
| Registered Nurse hours | 0.16 | 0.41 | 0.69 | bottom 4% in Oklahoma; bottom 1% in the U.S. |
| Weekend total nurse staffing | 4.08 | 4.16 | 3.50 | bottom 48% in Oklahoma; top 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.28 | 0.48 | bottom 10% in Oklahoma; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 59.7 | 55.5 | 45.8 | bottom 36% in Oklahoma; bottom 17% in the U.S. |
| RN turnover (%) | 0.0 | 53.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.58, RN 0.13, weekend 3.36. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Holland, Vernie | Individual | 5% or Greater Direct Ownership Interest | — | 09/03/2014 |
| Holland, Whitney | Individual | 5% or Greater Direct Ownership Interest | — | 09/03/2014 |
| Ponderosa Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | — | 03/21/2014 |
| Holland, Vernie | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/03/2014 |
| Holland, Vernie | Individual | ADP of the SNF | NOT APPLICABLE | 09/03/2014 |
| Kindle, Darlene | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Ponderosa Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/03/2014 |
| Reynolds, Ryan | Individual | ADP of the SNF | NOT APPLICABLE | 06/18/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What mental health services do you provide on-site, and who delivers them?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How quickly are lab tests done and results acted on when a resident's doctor orders them?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Covenant Living at Inverness | 2.8 mi | Tulsa, OK | ★★★★★ | 5/5 | |
| Colonial Manor Nursing Home | 3.6 mi | Tulsa, OK | ★★★★☆ | 3/5 | |
| Ambassador Manor Nursing Center | 4.0 mi | Tulsa, OK | ★★☆☆☆ | 2/5 | |
| Zarrow Pointe | 4.0 mi | Tulsa, OK | ★★★★★ | 4/5 | |
| The Villages at Southern Hills | 4.3 mi | Tulsa, OK | ★★★★★ | 5/5 | |
| Sand Springs Nursing and Rehabilitation | 5.2 mi | Sand Springs, OK | ★★☆☆☆ | 2/5 | abuse |
| Oklahoma Memory Care Institute | 5.2 mi | Tulsa, OK | ★★☆☆☆ | 2/5 | |
| Trinity Woods, INC. | 5.7 mi | Tulsa, OK | ★★★★★ | 5/5 | |
| University Village Retirement Community | 6.0 mi | Tulsa, OK | ★★★★☆ | 3/5 | |
| Saint Simeons Episcopal Home | 6.0 mi | Tulsa, OK | ★★★★☆ | 4/5 | |
| Southern Hills Rehabilitation Center | 6.0 mi | Tulsa, OK | ★★★☆☆ | 3/5 | |
| Grace Skilled Nursing and Therapy Jenks | 6.2 mi | Jenks, OK | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 375556.