Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to properly sanitize food contact surfaces, store and maintain kitchen equipment, and label or seal food items. Wet-stacked utensils, stained pans, soap residue, unlabeled foods, open packaging, and facility maintenance issues were observed. A dusty fan was in use near food prep, and a cell phone was found on a prep counter, all contributing to potential cross-contamination and foodborne illness risk.
Three residents experienced deficiencies in care when staff failed to notify physicians of significant weight changes as ordered, did not document required catheter measurements during dressing changes, and administered Midodrine outside of prescribed blood pressure parameters. Additionally, medication administration records were altered after the fact to correct initial documentation errors, contrary to facility policy.
Surveyors found that dietary staff did not follow facility recipes or measure ingredients when preparing meals, resulting in incomplete and inconsistent food preparation. Pureed foods were made with unmeasured water and thickener instead of the specified broth or sauce, and several residents reported that food was not served at appropriate temperatures. The Registered Dietitian and Dietary Supervisor confirmed that these practices did not meet facility expectations and could affect nutritional content and meal consistency.
Alternative meal options, such as grilled cheese and PB&J sandwiches, were provided to residents without additional protein sources, resulting in meals that did not match the nutritional value of the main entrée. The Registered Dietitian confirmed these alternatives were not equivalent in protein or calories compared to the main meal, which included chicken.
Staff reported that food brought in by families for residents was not stored due to the absence of a dedicated refrigerator, despite facility policy stating that such a refrigerator was available. As a result, residents were required to consume outside food within two hours or have it discarded.
Surveyors identified failures in infection prevention and control, including dust and debris on vents and fans in the clean linen area, incomplete lint cleaning logs, improper storage of clean items in soiled areas, and the storage of soiled linen and trash containers alongside medical supplies. Additionally, a resident using CPAP therapy had an opened, unlabeled container of distilled water stored on the floor, contrary to facility policy and infection control standards.
A resident with moderate cognitive impairment and a history of major depressive disorder repeatedly reported that the floor beside her bed was sticky, stained, and dirty. Despite daily housekeeping routines and staff acknowledgment of cleaning expectations, the area remained unclean for several days, failing to provide a safe, clean, and homelike environment as required by facility policy.
A resident with chronic atrial fibrillation and severe cognitive impairment, prescribed Warfarin, was not properly monitored for adverse reactions such as bruising as required by their care plan. Despite visible bruising and the resident's report of bruising easily, staff did not document or report these findings, and the weekly nursing summary did not reflect the presence of bruising. The DON confirmed the care plan required such monitoring, but records showed this was not done.
A resident with dry eye syndrome and moderate cognitive impairment did not receive a prescribed eye treatment (Theratears) ordered by an eye doctor for entropion. The order was not added to the medication list, and staff confirmed there was no documentation explaining why the treatment was not provided, despite facility policy requiring such interventions to be implemented and monitored.
Multiple Food Service Sanitation and Storage Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's food service operations, including improper sanitation practices and inadequate staff knowledge regarding the correct concentration of sanitizing solutions. Staff were observed using expired or undated test strips, not following manufacturer instructions for testing, and failing to achieve the required sanitizer concentration. Logs indicated that proper concentrations were recorded, but direct observation contradicted these records. The Registered Dietitian and Dietary Supervisor both acknowledged that improper sanitizer concentration could compromise surface sanitation and resident safety. Kitchen equipment and utensils were found to be improperly stored and maintained. Several pots, pans, bowls, and trays were stacked while still wet, creating an environment conducive to bacterial growth. Some cooking equipment, such as frying pans, were found to be darkened, stained, and scratched, making them difficult to clean and sanitize. Additional utensils and containers were observed with a white film or soap residue, indicating inadequate rinsing. Staff interviews confirmed that these items should have been air-dried and free of residue before storage and use. Food storage and facility maintenance issues were also documented. Sandwiches and gelatin in the refrigerator and dry storage lacked proper labeling, making it impossible to determine their safety for consumption. Opened food items in the freezer and dry storage were not properly sealed, and physical facility issues such as broken tiles and chipped paint compromised the ability to maintain a clean environment. A fan covered in dust was in use, blowing into the food preparation area, and a cell phone was found on a food prep counter, both presenting additional contamination risks. These deficiencies had the potential to lead to cross-contamination and foodborne illness for residents consuming facility-prepared meals.
Failure to Follow Professional Standards in Weight Monitoring, Catheter Care, and Medication Administration
Penalty
Summary
The facility failed to follow professional standards of care for three residents with significant medical needs. For two residents with congestive heart failure, daily weight monitoring was ordered with instructions to notify the physician if there was a weight change of three pounds or more in one day. Despite multiple instances where these weight changes occurred, there was no documented evidence that the physician was notified as required. Both the Director of Nursing (DON) and a licensed nurse confirmed that the physician should have been informed, and acknowledged the lack of documentation and communication regarding these significant weight fluctuations. For another resident with a midline catheter, the facility did not document required measurements of arm circumference and catheter length during dressing changes as ordered by the physician. The nurse responsible for the dressing change confirmed that the measurements were not recorded at the time of the procedure, and instead were entered several days later as late charting. The DON verified that the expectation was for these measurements to be documented at the time of the dressing change to allow for comparison and monitoring of the catheter site. Additionally, the same resident had a physician order for Midodrine to be held if systolic blood pressure (SBP) exceeded 130 mmHg. The medication was administered multiple times when the SBP was above this threshold, contrary to the order. Furthermore, the medication administration record (MAR) was altered after the fact to change the documentation from 'administered' to 'hold' for doses that should not have been given. The nurse involved admitted to initially documenting incorrectly and then backdating the correction, and the DON confirmed instructing the nurse to fix the charting. Facility policies require accurate, timely, and objective documentation, and prohibit erasures or deletions in the medical record.
Failure to Follow Food Preparation Recipes and Maintain Safe Food Temperatures
Penalty
Summary
Surveyors observed that food was not prepared according to facility recipes, with significant deviations in both ingredient selection and measurement. During meal preparation, the dietary cook omitted several required ingredients from the Sweet and Sour Chicken recipe, using only chicken, oil, pineapple, and bottled sauce instead of the full list of 17 ingredients. Ingredients were not measured, and the cook used unmeasured amounts of water and thickener when preparing pureed meals, contrary to the recipe instructions that specified using broth or sauce and following precise measurements. The Registered Dietitian and Dietary Supervisor confirmed that recipes and measurements are expected to be followed to ensure nutritional content and consistency. Additionally, the preparation of pureed foods did not adhere to the facility's provided recipes. The cook added water instead of the recommended broth or sauce, and did not measure the amount of liquid or thickener used, resulting in inconsistencies in the texture and nutritional value of the pureed meals. The process for pureeing both meats and vegetables was not followed as outlined in the facility's recipes, which require completing the regular recipe, measuring portions, and gradually adding the correct type and amount of liquid and stabilizer. Multiple residents reported that food was not served at appropriate temperatures, with complaints that hot food was not hot and cold food was not cold. The Dietary Supervisor acknowledged receiving complaints about food temperature, particularly from one hallway, but was unsure of the root cause. These failures in food preparation and service had the potential to negatively impact the intake and nutritional status of the residents receiving facility-prepared meals.
Alternative Meal Options Lacked Equivalent Nutrition
Penalty
Summary
During a kitchen observation at lunch meal plating, it was noted that alternative food options provided to residents, specifically grilled cheese and peanut butter and jelly (PB&J) sandwiches, were not of similar nutritive value to the main entrée. One resident received a grilled cheese sandwich as an alternative to the main meal, and another had a standing order for a half PB&J sandwich with a cup of soup instead of the main meal. The Registered Dietitian confirmed that these alternatives lacked an additional protein source, such as cottage cheese or yogurt, which would be necessary to make the meal nutritionally equivalent to the main entrée. Review of the facility's recipes showed that the grilled cheese and PB&J sandwiches provided less protein and fewer calories compared to the main meal, which included 4 ounces of chicken and provided over 700 calories and 32 grams of protein.
Lack of Resident Food Storage for Outside Food
Penalty
Summary
The facility failed to provide a dedicated refrigerator for storing food brought in by family or visitors for residents. Certified Nursing Assistants and a Licensed Nurse confirmed during interviews that while food could be brought in and checked for dietary compliance and safety, residents were only allowed two hours to consume it, after which it would be discarded due to the lack of storage. The facility's policy indicated that a resident refrigerator and microwave were available if needed, but staff interviews revealed that no such refrigerator was accessible for resident use, resulting in the inability to store preferred foods brought from outside.
Infection Control Failures in Laundry, Storage, and Respiratory Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. In the clean linen area, dust particles were found on vents above the area and blackish particles had accumulated on the fan blades. The Housekeeping and Laundry Supervisor confirmed these findings and acknowledged that the fan was dirty and should have been cleaned. Additionally, the daily lint cleaning log was incomplete for a specific shift, despite laundry being processed during that time, and clean items such as pillows and mop heads were stored in the soiled linen area. The supervisor confirmed that all staff are responsible for keeping the laundry area clean and that vents are cleaned monthly or as needed. Further deficiencies were observed in the utility room, where soiled linen and trash containers were stored alongside medical supplies, oxygen concentrators, and personal hygiene items. One container was overflowing with the lid open, and a clear plastic bag containing soiled linen was present. Both the Infection Preventionist and the Director of Nursing confirmed that this storage practice posed a risk for cross contamination and agreed that clean items should not be stored in the dirty linen room. Facility policies reviewed indicated that storage areas should be kept clean and free from trash, and that soiled linen should be handled with standard precautions to prevent contamination of clean linen. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, an opened and unlabeled container of distilled water was observed on the floor in the resident's room, which was being used nightly for CPAP therapy. The Infection Preventionist initially stated it was acceptable for the jug to be on the floor, but later clarified that it should not be placed there due to infection control concerns. Nursing staff confirmed that distilled water is used for CPAP and should not be kept on the floor, and that opened containers should be labeled. Facility policies required distilled water used in respiratory therapy to be dated and initialed when opened, and discarded per manufacturer guidelines, but these procedures were not followed.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have a sticky, stained, and dirty floor on multiple occasions. The resident, who had a history of major depressive disorder and moderate cognitive impairment, expressed dissatisfaction with the cleanliness of her room, specifically noting that the area beside her bed had not been cleaned despite her complaints. Observations over several days confirmed the presence of dried, sticky stains on the floor, and the resident reported that housekeeping had either not cleaned the area or had not done so adequately. Housekeeping staff were observed cleaning the room but failed to address the specific area of concern. The Housekeeping and Laundry Supervisor stated that all surfaces, including the sides and under the bed, should be cleaned, and the DON agreed that the resident should have a clean and homelike environment. The facility's policy also required a clean and sanitary environment. Despite these expectations, the area remained unclean for several days, resulting in a failure to provide a safe, clean, and homelike environment for the resident.
Failure to Implement Anticoagulant Monitoring Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident receiving anticoagulant therapy. The resident, who had chronic atrial fibrillation and severe cognitive impairment, was prescribed Warfarin and had a care plan in place that required monitoring, documentation, and reporting of adverse reactions such as bruising. Despite this, clinical records and interviews revealed that there was no documentation or reporting of the resident's bruising prior to a specific date, even though the resident was observed with bruises on both arms and reported bruising easily. Nursing staff confirmed that while they usually documented bruising at blood draw sites, there was no current monitoring or documentation for the resident's bruises, and no report was made regarding the bruises on the morning of the observation. The Director of Nursing confirmed that the care plan included monitoring for adverse reactions to anticoagulant therapy, but the weekly nursing summary did not indicate the presence of bruising. The facility's policy required comprehensive, person-centered care plans that reflect recognized standards of practice, but there was no documented evidence that the resident's bruising was monitored or reported as required by the care plan.
Failure to Implement Eye Doctor's Order for Vision Treatment
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of dry eye syndrome and moderate cognitive impairment did not receive prescribed treatment to maintain visual function. The resident's care plan identified impaired visual function related to dry eyes and included instructions to review medications for side effects affecting vision. An eye doctor consultation documented a new order for Theratears, to be administered three times daily to the resident's right eye due to entropion. However, this order was not added to the resident's active medication list, and there was no documentation explaining why the order was not carried out. Interviews with facility staff confirmed that new orders from specialists are typically verified and implemented, with the DON notified of changes. Despite this process, the DON acknowledged that the eye doctor's order for Theratears was not executed and that there was no record of the rationale for this omission. The facility's policy required staff to adjust interventions based on physician orders and changes in the resident's condition, but this protocol was not followed in this instance.
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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.
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Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mckinley Park Care Center | 1.2 mi | ★★★★★ | 31 | 0 |
| Saylor Lane Healthcare Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Woodside Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Asbury Park Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 20 | 0 |
| Advanced Health Care Of Sacramento | 1.7 mi | ★★★★★ | 1 | 0 |
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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.