Complete Care at Sheriden Commons

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all portions of the call light systems are working by ensuring the system can be heard away from the nurses' station on the second and third floor of the facility. This failure affected 8 residents (R1, R6, R7, R8, R9, R10, R11, and R12) of 10 residents reviewed for the facility's call light system on the second and third floor unit. On 4/6/2026 at 1:49 PM, R1 stated R1 stated that response times to call lights vary depending on who is on the floor; sometimes staff respond quickly, but at times the call light stays on for 20-30 minutes and the call light on the unit was broken for about two months. On 4/8/2026 at 9:30 AM, surveyors tested the new call light system in the hallway of wing B on the third floor by R8's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' received accommodation in the correct incontinent product size as evidence by the facility ordering only a size 3 extra-large for resident measuring a size 5 extra-large per the incontinent product brand's measuring guidelines. This failure affected 2 of 2 residents (R1 and R3) reviewed for incontinent product sizing. A.On 4/6/2026 at 1:49 PM, R1 stated incontinence briefs provided by the facility do not fit her (R1); she weighs about three hundred and fifty pounds or more and residents are told these are the only sizes available. On 4/6/2026 at 2:26 PM, V7 (certified nurse assistant) stated she (V7) noted occasional issues obtaining size 3, 4, or 5 incontinent products if shipments arrive late. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff donned appropriate PPE (Personal Protective Equipment) while providing high contact resident care for a resident (R77) on EBP (Enhanced Barrier Precautions), failed to perform hand hygiene during a wound dressing change for a resident (R77), failed to ensure that urine collection canister was not placed on the floor, failed to ensure EBP signs were posted and PPE bins were available for 2 (R14 and R17) residents on EBP, and failed to sanitize medication tray between residents (R7 and R44) usage. These failures affected 5 (R7, R14, R17, R44, and R77) residents reviewed for infection control and have the potential to affect all 41 residents on the second floor and all 40 residents on the third floor.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure that residents' Low Air Loss Mattresses (LALM) for pressure ulcer prevention are set at the correct weight settings. This failure affected four residents (R4, R25, R37, R77) out of four residents reviewed for pressure ulcer prevention and treatment in a sample of 45 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow Pharmacy recommendation for medication storage, failed to ensure multidose medications have open and discard dates, failed to ensure the refrigerator was within the temperature range for proper storage of medication, and failed to ensure a treatment cart was kept locked when unattended. These failures affected 3 (R29, R57, and R83) residents reviewed for medication storage and have the potential to affect all 41 residents on the second floor and all 40 residents on the third floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve hot foods to the residents at a temperature of 135 degrees Fahrenheit (F) per facility policy. This failure has the potential to affect all 42 residents residing on the 3rd floor receiving an oral diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the indwelling catheter drainage bag was covered for dignity. This failure affected 1 (R51) resident reviewed for indwelling catheter in the total sample of 45 residents.

Inspectors wroteBased on observation, interview, and record interview, the facility failed to complete Medication Self-Administration Safety Screen Assessment and failed to get an order to, may self-administer medication and treatment prior to a resident initiating self-administration of medication and treatment. This failure affected 1 (R36) resident reviewed for self-administration of medication in the total sample of 45 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to label and date oxygen equipment (oxygen tubing) and failed to properly contain oxygen equipment (Bilevel Positive Airway Pressure mask and oxygen tubing) when not in use. These failures affected two residents (R52 and R233) reviewed for respiratory care in a sample of 45 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide routine dental services for one resident (R54) whose teeth are dark with multiple holes in his teeth.

Inspectors wroteBased on interview and record review, the facility failed to identify and treat the cause of new pain in left arm; failed to timely review x-ray results; failed to relay x-ray results to physician; failed to obtain verbal or telephone order from physician for pain patch for one resident (R4) in a total sample of 3 residents (R4, R5, and R6). These deficient practices resulted in harm for R4 experiencing new onset left arm pain for 34 days with limited mobility due to a left humerus fracture diagnosed at an outside hospital.

Inspectors wroteBased on interview and record review the facility failed to properly assess and manage oral fluid intake, urinary output and bowel output in a resident (R4) who was at risk for dehydration. This deficient practice resulted in harm for one resident (R4) requiring hospitalization for acute kidney disease and fecal impaction.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to follow their policy on Sanitation & Safety Operations by (a) failing to maintain proper food temperatures, (b) failing to date opened food items with open and use by date, (c) failing to unload clean dishes from the dishwasher in a sanitary manner. (d) dishwasher temperatures not consistently documented. These deficiencies have the potential to affect 76 residents who are on an oral diet and receiving meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 4 out of 22 shifts and b.) keep an accurate count of all narcotic medications for two (R11, R22) residents reviewed for medications. These failures have the potential to affect 42 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect 35 residents residing in the facility. Findings Include: On 02/07/2024 at 8:09AM, surveyor located on the second floor of the facility. During medication administration pass with V11 (LPN), V11 observed preparing liquid antibiotic medication for R57. V11 observed leaving liquid antibiotic medication on top of his medication cart (identified as Team 2 medication cart) and walks away leaving the liquid medication unattended and out of V11's view. On 02/07/2024 at 8:09AM, V11 returns to the medication cart and states to surveyor, I knew you were standing here so that's why I left the medication on top of the cart. Surveyor states to V11 that surveyor is not responsible for monitoring V11's medication cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide their bed hold policy, upon discharge to hospital, for one (R74) out of three residents reviewed for discharge.

Inspectors wroteBased on interview and record reviews the facility failed to refer three (R5, R24, R30) residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two low air loss mattresses were set according to manufacturer recommendation for residents (R29, R33) who are identified as high risk for pressure injury.

Inspectors wroteBased on interviews and records review, the facility failed to obtain consent for psychotropic medication administration for two (R24, R34) residents reviewed for psychotropic medications in a sample of 18 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R23, R57) out of four residents reviewed for medication administration resulting in an 11.11% error rate. Findings Include: R57's medication administration record (MAR) dated 02/01/2024- 02/07/2024 documents: Nebivolol HCL 5mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 02/07/2024 at 8:24AM, surveyor observed that this medication was not given during the 9:00AM medication administration pass with V11 (Licensed Practical Nurse/LPN). R23's medication administration record (eMAR) dated 02/01/2024 - 02/07/2024 documents: Protonix 40mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. Valsartan 80mg- Give 2 tablets by mouth two times a day scheduled at 9:00AM. [...]

Inspectors wroteBased on interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination with its education for 3 residents (R15, R229 and R49) out of 5 in a sample of 18.

Inspectors wroteBased on record review and interview, the facility failed to employ a full time Social Service Director. This has the potential to affect all 78 residents residing in the facility whom require medical social services.

Inspectors wroteBased on interview and record review, the facility failed to ensure six residents (R5, R6, R13, R17, R21, R29) were given the right to participate in the development and implementation of their person-centered plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents (R12, R26, R30) have a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) provide supervision and monitoring for residents during the designated smoking time to ensure residents practice safe smoking in the designated area and b.) failed to complete a quarterly smoking safety evaluation as required. These failures affected three (R30, R31, R32) residents reviewed for smoking safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the (Facility) Daily Staffing was up to date and posted in a prominent location that is readily accessible to staff and visitors. This failure has the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document temperature readings on the freezer and cooler temperature logs. This has the potential to affect 85 residents in the facility who receive an oral diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain shift change accountability records for controlled substances that enables periodic reconciliation and accounting for residents' controlled medications. This failure has the potential to affect all 42 residents on the second floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a timely response to an activated call light for one resident (R38) and failed to provide a call device for one resident (R60) in the total sample of 40 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the cleanliness of a personal refrigerator, failed to provide a thermometer and maintain a temperature log for the personal refrigerator, and failed to ensure food stored in the personal refrigerator was dated to prevent foodborne illness for one resident (R21) out of 4 residents reviewed in the total sample of 40 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to clip or trim the fingernails of one resident (R54) out of three residents reviewed for fingernail care.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that a resident's (R84) blood pressure was measured before administering a heart medication as ordered by the Physician and failed to ensure that the resident's (R84) Heart rate was properly measured as ordered by the Physician. This failure has the potential affect all residents that reside in the facility and who relies on a Nurse to follow Doctor's orders pertaining to their care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for one resident (R63). This failure affected one resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 40.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow the medication labeling and storage policy by not documenting an open date on eye drops. This failure affected two residents (R37 and R75). This failure was identified on two medication carts reviewed for medication labeling and storage out of four carts.