Inspection Reports for
Sherwood Nursing and Rehabilitation Center, Inc.
245 Indian Bay Drive, Sherwood, AR, 72120
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
96% occupied
Based on a September 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident (Resident #98) was improperly transferred using a mechanical lift by one staff instead of two as required, resulting in a fall and serious injury.
Complaint Details
The complaint investigation was substantiated. Resident #98 was transferred using a one-person mechanical lift transfer instead of the required two-person transfer, resulting in a fall with severe injuries and death five days later. The responsible CNA was terminated. The facility implemented retraining and monitoring to prevent recurrence.
Findings
The facility failed to ensure two staff assisted in transferring Resident #98 using a mechanical lift as required by the care plan, resulting in a fall causing severe head injury and subsequent death. The facility terminated the responsible CNA, retrained staff, and implemented monitoring to prevent recurrence. Additionally, a separate infection control deficiency was found related to improper hand hygiene during perineal care for Resident #106.
Deficiencies (2)
Failure to ensure two staff assisted in mechanical lift transfer of Resident #98, resulting in fall and serious injury.
Failure to perform proper hand hygiene during perineal care for Resident #106.
Report Facts
Incident time: 530
Years resident lived at facility: 7
Years Administrator employed: 6
Number of staff files reviewed: 7
Dates of nursing return demonstrations: 09/18/2025 and 11/11/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Performed improper one-person mechanical lift transfer causing resident fall; terminated. |
| Director of Nursing | Director of Nursing (DON) | Documented incident, led investigation, implemented retraining and monitoring. |
| Administrator | Facility Administrator | Informed of incident, oversaw corrective actions and staff training. |
| LPN #11 | Licensed Practical Nurse | Responded to incident, provided emergency care, and described facility policies. |
| LPN #12 | Licensed Practical Nurse | Responded to incident, called 911, and assisted with emergency care. |
| Physician Assistant | Physician Assistant (PA) | Recalled incident and medical consequences of resident fall. |
| CNA #9 | Certified Nursing Assistant | Observed improper hand hygiene during perineal care for Resident #106. |
| CNA #16 | Certified Nursing Assistant | Observed improper hand hygiene during perineal care for Resident #106. |
Inspection Report
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the completion of baseline care plans within 48 hours of admission for newly admitted residents.
Findings
The facility failed to ensure baseline care plans were completed within 48 hours of admission for 4 residents reviewed. Interviews and record reviews confirmed no baseline care plans were completed for Residents #301, #351, #352, and #357.
Deficiencies (1)
Failure to create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted for 4 residents.
Report Facts
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated the facility did not have a policy for baseline care plans and confirmed baseline care plans had not been completed for the residents | |
| Director of Nursing | Confirmed baseline care plans had not been completed for the residents | |
| Medicare (MCR)/MDS Coordinator | Stated baseline care plans are done on admission and signed by responsible party or resident; was unable to locate baseline care plans for the residents |
Inspection Report
Routine
Census: 94
Deficiencies: 6
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, housekeeping, MDS assessments, care planning, dietary services, and infection control at Sherwood Nursing & Rehabilitation Center.
Findings
The facility was found deficient in maintaining a clean and homelike environment in resident rooms, timely completion and transmission of discharge MDS assessments, baseline care plans within 48 hours of admission, dialysis care planning, proper food storage and handling in the dietary department, and adherence to infection prevention and control protocols including hand hygiene and PPE use.
Deficiencies (6)
Failed to ensure resident rooms were clean, safe, and homelike, with trash and used gloves observed in Resident #357's room over multiple days.
Failed to complete and transmit discharge Minimum Data Set (MDS) for Residents #44 and #93.
Failed to complete baseline care plans within 48 hours of admission for Residents #301, #351, #352, and #357.
Failed to develop and implement a dialysis care plan for Resident #351.
Failed to ensure proper food storage, removal of expired items, and proper hygiene practices in dietary services, including contaminated handling of clean plates and unclean ice machine conditions.
Failed to ensure proper hand hygiene and proper wearing and removal of personal protective equipment for Resident #355 on enhanced barrier precautions.
Report Facts
Resident census: 94
Residents reviewed for baseline care plans: 4
Residents reviewed for MDS accuracy and timing: 2
Residents reviewed for dialysis care planning: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency related to improper hand hygiene and PPE use with Resident #355 |
| Dietary Manager | Mentioned in dietary deficiencies related to food storage, expired items, and ice machine sanitation | |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in baseline care plans and infection control education for LPN #1 |
| Administrator | Administrator | Confirmed housekeeping and care planning deficiencies |
| Housekeeping Supervisor | Housekeeping Supervisor | Acknowledged poor room cleanliness for Resident #357 |
| Medicare (MCR)/MDS Coordinator | Confirmed missing discharge MDS and baseline care plans |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a Certified Nursing Assistant (CNA) transferred a resident requiring two-person assistance alone, resulting in the resident falling and sustaining injuries.
Complaint Details
The complaint investigation substantiated that a CNA transferred Resident #1 alone using a mechanical lift, causing the resident to fall and sustain a hematoma and skin tear. The CNA was suspended pending investigation and later terminated. Multiple staff interviews confirmed the requirement of two staff for mechanical lifts and that the incident violated this policy.
Findings
The facility failed to ensure two staff members were present during the transfer of a resident requiring two-person assistance, leading to a fall with injury. The CNA involved was suspended and subsequently terminated. Interviews and documentation confirmed the requirement for two staff during mechanical lifts and that this protocol was not followed.
Deficiencies (1)
Failure to ensure two staff members were present when transferring a resident requiring two-person assistance, resulting in a fall and injury.
Report Facts
Date of incident: Oct 7, 2023
Date of survey completion: Oct 17, 2023
Number of staff required for mechanical lift: 2
Number of residents sampled: 3
Date of competency check-off for CNA #1: Oct 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Involved in the incident transferring resident alone, suspended and terminated | |
| Licensed Practical Nurse (LPN) | Assessed resident after fall and provided statements regarding incident | |
| Director of Nursing (DON) | Interviewed regarding incident and confirmed two staff required for mechanical lifts | |
| Administrator | Conducted investigation and decided to terminate CNA #1 |
Inspection Report
Routine
Census: 91
Deficiencies: 6
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, including the upkeep of resident equipment and living spaces.
Findings
The facility failed to ensure that resident equipment and living spaces were maintained in a clean and serviceable manner, with observations of dirt, debris, rust, dried formula, and unclean linens affecting multiple residents' rooms and equipment.
Deficiencies (6)
Wheelchair with dirt, debris, food crumbs, and dust on spokes and metal parts.
Rooms with multiple areas of dust, lint, overflowing trash cans, and rust on raised toilet chair metal bars.
Tube feeding pole with dried formula and floor with dried liquid, dirt, dust, and debris.
Walker covered with dust, debris, and greasy substance.
Beds with pillows lacking pillowcases, residents reporting lack of basic hygiene supplies.
Wheelchair cushions littered with debris including food particles, lint, and dirt.
Report Facts
Residents present: 91
Inspection Report
Routine
Census: 91
Deficiencies: 4
Date: Sep 18, 2023
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations related to resident living conditions, medication storage, accident hazards, and food safety at Sherwood Nursing & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including unclean resident equipment and living spaces, unsafe medication storage practices, inadequate supervision to prevent accidents, and failure to ensure proper hand hygiene and food storage in the kitchen. These issues posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failure to maintain resident equipment and living space in a clean, serviceable manner affecting 91 residents.
Failure to ensure medications were stored safely, potentially affecting 1 resident.
Failure to ensure nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, affecting few residents.
Failure to ensure staff sanitized hands between assisting residents with eating and failure to properly seal and store food, potentially affecting 89 residents.
Report Facts
Residents affected: 91
Residents affected: 1
Residents affected: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Confirmed medications that are creams and powders should be stored in the medication cart |
| Director of Nurses | DON | Confirmed medications, creams, and powders should be stored on nurses' cart, treatment cart, or medication room; confirmed hand hygiene requirements |
| Administrator | Confirmed lack of policies concerning daily housekeeping, medication storage, and hand hygiene | |
| Assistant Dietary Manager | ADM | Confirmed chicken patties in kitchen should be sealed |
| Certified Nurse Aid | CNA | Confirmed hands should be sanitized between assisting residents with eating |
| Nurse Aid | NA | Observed assisting residents without handwashing or sanitizing |
| Head of Housekeeping | Confirmed findings of unclean resident equipment and living space |
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