Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Nursing & Rehabilitation Center, Inc during CMS and state inspections, most recent first.
A resident who was care planned for a two-person mechanical lift transfer was moved by one CNA alone, despite the resident’s care plan, closet care plan, MDS, and the lift manufacturer’s guidance requiring two assistants. The resident fell from the lift and sustained a laceration to the eyebrow, injury and bleeding from the eye, and pain to the head and shoulder. Staff and the roommate described the resident lying in blood on the floor, with the sling still on the lift, and the DON reported the CNA later admitted trying to complete the transfer alone.
Hand Hygiene Not Performed During Perineal Care: Two CNAs provided perineal care to a resident with CHF, COPD, AFib, and severe cognitive impairment while wearing the same dirty gloves across dirty and clean tasks. They wiped the resident, applied cream, handled a clean brief and clothing, touched bedrails and the bed remote, returned cream to the bedside drawer, and one CNA offered fluids after removing gloves without performing hand hygiene. The DON stated staff were expected to wash hands and change gloves during perineal care, and the Administrator confirmed there was no hand hygiene policy.
The facility's kitchen failed to maintain proper food safety and hygiene standards, affecting resident meals. Issues included undated and expired food items, improper storage, and inadequate hand hygiene practices by dietary staff. Additionally, one ice machine was not clean, and staff mishandled glassware, increasing cross-contamination risks.
A resident's room and bathroom were found to be unclean and not homelike, with trash accumulating in various areas and uncovered bedpans and basins in the bathroom. Despite claims of cleaning, observations over several days confirmed the ongoing presence of debris. The facility's Administrator and Housekeeping Supervisor acknowledged the issue and expressed intent to address it.
The facility failed to complete and transmit discharge MDS assessments for two residents, one with moderate cognitive impairment and another cognitively intact, leading to a deficiency in MDS accuracy and timing. The oversight was attributed to the MCR/MDS Coordinator being busy and forgetting.
The facility failed to complete baseline care plans within 48 hours of admission for four residents with various medical conditions, including congestive heart failure and post laminectomy syndrome. Despite regulatory requirements, the facility did not have a policy for baseline care plans, and the absence of these plans was confirmed by staff during interviews.
A facility failed to initiate a dialysis care plan for a resident with end-stage renal disease, despite the resident's MDS indicating the need for hemodialysis. The care plan lacked interventions for dialysis, and interviews with the DON and MDS coordinator confirmed the absence of a dialysis order and care plan, with no explanation provided for the oversight.
A facility failed to ensure proper hand hygiene and PPE use for a resident under enhanced barrier precautions. An LPN did not sanitize hands before donning gloves, improperly wore and removed an isolation gown, and failed to change gloves between tasks. The resident had multiple diagnoses requiring enhanced precautions. The DON confirmed the LPN's errors and planned to provide further education.
Improper One-Person Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that two staff assisted with a mechanical lift transfer for a resident whose care plan and closet care plan both required a two-person mechanical lift transfer with a purple sling. The resident’s MDS also indicated dependence on two or more helpers for transfer. The lift manufacturer’s user manual identified two assistants as the recommendation for all lifting preparation, transferring from, and transferring to procedures, and warned that failing to follow this recommendation could result in death or serious injury. On the morning of the incident, CNA #1 attempted to transfer the resident using the mechanical lift with only one person assisting. The resident fell from the lift and sustained a laceration to the right eyebrow, injury to the right eye with bleeding from the eye, and complaints of pain to the head and right shoulder. The resident was sent to the emergency room for further evaluation. The resident’s roommate stated they told the CNA that two people were needed, heard the CNA say they would wait for the other CNA, and then heard a loud noise before seeing the resident lying in blood on the floor. Multiple staff accounts described that the resident was found face down with blood near the head and that the sling was still on the lift. The DON stated CNA #1 initially said the resident rolled out of bed, then admitted trying to lift the resident alone. The facility investigation also documented that CNA #1 knew two people were required but said they could not find help quickly enough. The resident had diagnoses including encephalopathy, altered mental status, heart failure, chronic pulmonary edema, cognitive communication deficit, muscle wasting and atrophy, lack of coordination, ischemic cardiomyopathy, diabetes, polyneuropathy, osteoarthritis, and lower back pain.
Hand Hygiene Not Performed During Perineal Care
Penalty
Summary
Proper hand hygiene was not performed during perineal care for one resident who had diagnoses of congestive heart failure, COPD, and atrial fibrillation, and whose admission MDS showed a BIMS score of 06 indicating severe cognitive impairment. The MDS also indicated the resident was incontinent of bowel and occasionally incontinent of bladder. During an observation, two CNAs assisted the resident into bed, removed the pajama bottoms while wearing gloves, and provided perineal care. One CNA wiped the perineal area and buttocks, applied cream after removing a wet brief, and then removed skin cream from the bedside drawer without changing gloves or performing hand hygiene. The same CNAs continued care while wearing the same dirty gloves, placing a clean brief, pulling up clean pajama bottoms, adjusting linens, touching bedrails, and returning skin cream to the bedside drawer. One CNA also touched the bed rails and bed remote to lower the bed and raise the resident's head while still wearing the same dirty gloves, then removed the gloves and offered fluids without performing hand hygiene before opening the bedside drawer. Both CNAs stated hand hygiene should be performed during perineal care, including changing gloves and washing hands before touching clean items. The DON stated staff were expected to wash hands and change gloves during perineal care, and the Administrator confirmed the facility did not have a hand hygiene policy.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in its kitchen, affecting the meals served to residents. Observations revealed that dented food cans were not promptly removed or discarded, and expired food items and spices were not disposed of by their expiration dates. Additionally, food stored in the freezer and dry storage areas lacked proper dating to ensure a first-in, first-out system. Dietary staff were observed not wearing hairnets, which could lead to cross-contamination, and serving dishes were improperly stored, exposing them to potential contamination. Furthermore, one of the two ice machines was not maintained in a clean and sanitary condition, and dietary staff mishandled glassware, increasing the risk of cross-contamination. Specific incidents included uncovered plates in the plate warmer, an undated can of instant food thickener, a dented can of corn, and exposed desert-sized plates. Hand hygiene practices were also inadequate, with staff failing to wash hands properly after handling dirty objects and before handling clean equipment. Expired food items, such as potato salad and poultry seasoning, were found in storage, and several containers of ice cream and leftover food lacked proper dating. Additionally, a wet, black residue was observed on screws above an ice machine, which could potentially drip onto the ice used by Certified Nursing Assistants for residents' water pitchers.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for a resident, as evidenced by multiple observations of unclean conditions in the resident's room and bathroom. The resident, who had moderate cognitive impairment, was admitted with diagnoses including fusion of the spine and lower back pain. Observations over several days revealed trash accumulating in various areas of the room, including under the bed, along the walls, and behind the door. Additionally, the bathroom contained an uncovered bedpan and wash basin, with a brown stain noted on the shower stall floor. Despite the resident's report that housekeeping had cleaned the room, the surveyor continued to find trash and debris in the room and bathroom. Interviews with the facility's Administrator and Housekeeping Supervisor confirmed the unclean conditions, with both acknowledging the presence of trash and used gloves in the room and bathroom. The Housekeeping Supervisor expressed regret over the state of the room and indicated that it would be addressed.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure the completion and transmission of discharge Minimum Data Set (MDS) assessments for two residents, leading to a deficiency in MDS accuracy and timing of assessments. Resident #44, admitted with diagnoses including pulmonary embolism and acute respiratory failure with hypoxia, was discharged without a completed discharge MDS. Similarly, Resident #93, admitted with sepsis, acute kidney failure, and acute cholecystitis, was also discharged without a completed discharge MDS. Both residents had their 5-day MDS assessments completed, indicating moderate cognitive impairment for Resident #44 and cognitive intactness for Resident #93. The deficiency was confirmed during a review of the closed electronic medical records, which showed no discharge MDS assessments for the two residents. The Medicare/MDS Coordinator acknowledged the oversight, stating that the discharge MDS should have been completed and transmitted within 14 days post-discharge. The Administrator attributed the error to the MCR/MDS Coordinator being busy and forgetting, acknowledging that such omissions are not typical for the facility.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for four residents. This deficiency was identified through observations, interviews, and record reviews. The facility admitted residents with various medical conditions, including congestive heart failure, atrioventricular block, and post laminectomy syndrome, but did not create baseline care plans for any of them. The absence of these care plans was confirmed by the facility's Medicare/MDS Coordinator and the Administrator, who acknowledged that the plans were not completed. The report highlights that the facility did not have a policy for baseline care plans, despite it being a regulatory requirement. The MDS assessments for the residents indicated varying levels of cognitive function, with some residents being cognitively intact and others having moderate cognitive impairment. Despite these assessments, the necessary baseline care plans were not found in the electronic medical records, and the facility staff confirmed their absence during interviews.
Failure to Initiate Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to initiate a dialysis care plan for Resident #351, who was admitted with diagnoses including heart disease, retention of urine, and end-stage renal disease. The resident's 5-day Minimum Data Set (MDS) indicated moderate cognitive impairment and noted that the resident was receiving hemodialysis. However, a review of the resident's care plan, initiated on 08/19/2024, revealed the absence of a dialysis care plan with interventions. During interviews, the Administrator acknowledged the lack of a care planning policy, assuming it was covered by regulations. The Director of Nursing (DON) confirmed the absence of a dialysis order and care plan, despite being aware of the resident's need for dialysis and the presence of a Quinton catheter. The Medicare/MDS coordinator also confirmed the lack of a dialysis order and care plan, without providing an explanation for the oversight.
Infection Control Deficiency in PPE Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and the correct use of personal protective equipment (PPE) for a resident under enhanced barrier precautions. The facility's policies on hand hygiene and isolation precautions were not followed by a Licensed Practical Nurse (LPN) during the administration of medication to a resident. The resident, who was admitted with diagnoses including infection and inflammatory reaction due to an internal joint prosthesis, sepsis, and ulcerative colitis, was on enhanced barrier precautions. The resident's care plan required staff to wear appropriate PPE and educate others on these procedures. During an observation, the LPN was seen putting on gloves without sanitizing hands first, retrieving an isolation gown from outside the resident's room, and then entering the room with the gown and gloves on. The LPN handled various items and performed medical procedures without changing gloves or sanitizing hands between tasks. The LPN also left the resident's room wearing the isolation gown, removed it in the hallway, and disposed of it improperly, which was against the facility's policy. Interviews with the LPN and the Director of Nursing (DON) confirmed the lapses in following infection control protocols. The LPN admitted to not sanitizing hands before putting on gloves and acknowledged that the gown should not have been put on at the medication cart. The DON confirmed that the LPN was a new employee and stated that education on infection control and enhanced barrier precautions would be provided to the LPN. The DON also confirmed that the isolation gown and gloves should not be removed in the hallway.
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 111 citations issued within 25 miles in the last 12 months — including the 1 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 Sherwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Premier At The Springs | 4 mi | ★★★★★ | 6 | 0 |
| Woodland Hills Healthcare And Rehabilitation | 4.2 mi | ★★★★★ | 0 | 0 |
| Lakewood Health And Rehab, Llc | 4.3 mi | ★★★★★ | 2 | 0 |
| Robinson Nursing And Rehabilitation Center Llc | 5.1 mi | ★★★★★ | 0 | 0 |
| The Blossoms At North Little Rock Rehab & Nursing | 7.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sherwood Nursing & Rehabilitation Center, Inc.
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.