Sheridan Health and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility did not notify 2 of 6 (R1 and R5) resident's representatives of the need to transfer to the hospital. R5's representative was not notified when they were transferred to the hospital. R1's representative was not notified when they were transferred to the hospital.

Inspectors wroteBased on observation and interview the facility did not provide a safe, clean, comfortable and home-like environment for 1 (R7) of 4 resident's rooms observed. On 6/15/26 and 6/16/26 food crumbs, paper, and other debris were observed under & around R7's bed and under the bedside dresser.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 2 of 2 Residents (R1 and R2) of 11 sampled residents. A facility reported incident (FRI) submitted to the State Agency on 5/8/26 stated that R1 had communicated that R2 had been harassing R1 which included R2 watching R1 when R1 slept. The FRI did not contain staff interviews or statements of who may have witnessed inappropriate behaviors from R2 directed at R1 or other residents. Based on record review and staff interviews, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 2 of 2 Residents (R1 and R2) of 11 sampled residents. [...]

Inspectors wroteBased on interview and record review the facility did not provide a comprehensive care plan for 3 (R1, R2, and R10) of 11 residents reviewed for care plans*R1 had a history of trauma and did not have a comprehensive care plan with person centered interventions for trauma.*R2 had a history of trauma and did not have a comprehensive care plan with person centered interventions for trauma. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R4) of 5 sampled residents reviewed for activities of daily living (ADL) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene.*R4 did not receive weekly shower on 1/27/26 and 3/10/26.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 2 (R3 of R7) of 4 residents had a comprehensive assessment and care plan to either prevent and/or heal pressure injuries. R7 had a deep tissue injury upon admission. On 4/2/26 Wound Physician-G assessed R7's pressure injury as a Stage 3 left buttocks pressure injury and ordered a treatment. The order wasn't picked up until 4/4/26 and was transcribed incorrectly. R7's pressure injury was documented as healed on 4/9/26. There was no update to the care plan to address the potential for impaired skin integrity. The pressure injury reopened on 4/23/26. The facility didn't revise R7's pressure injury care plan nor was there any evidence the facility reviewed the care plan and determined the care plan remained appropriate after R7's pressure injury reopened. [...]

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not implement person centered interventions for substance use disorder (SUD) for 1 of 1 resident (R2) reviewed for SUDs. Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not implement person centered interventions for substance use disorder (SUD) for 1 of 1 resident (R2) reviewed for SUDs.

Inspectors wroteBased upon observation, interview and record review, the facility did not ensure 2 (R1 and R11) of 4 sampled residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being.*R1and R11were in an intimate relationship and the facility did not complete an Intimate and Sexual History and did not complete a comprehensive care plan with person centered interventions.

Inspectors wroteBased on interview and record review the facility did not provide pharmaceutical services to meet the needs of each resident for 1 (R4) of 1 sample resident. R4's blood sugar was not monitored to determine whether R4 required Novolog sliding scale three times daily and R4's Lantus 4 units at bedtime was not administered on 2/6/26 and 3/18/26.

Inspectors wroteBased on interview and record review the facility did not ensure a resident's physician was promptly notified of laboratory results that fall outside of clinical reference ranges for 1 (R4) of 1 sample resident. R4's physician was not notified of abnormal laboratory results on 4/10/26 and 4/21/26.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R7) of 2 Residents.*Staff were not wearing gowns during care observations for R7 who is on EBP (enhanced barrier precautions) and appropriate hand hygiene was not observed during pressure injury treatment.

Inspectors wroteBased on interview and record review, the facility did not ensure a registered nurse (RN) worked at the facility for at least eight (8) consecutive hours a day, seven days a week, on 1 of 30 days reviewed. This deficient practice had the potential to affect all 56 residents residing at the facility on 12/14/2025. The facility did not have a RN working in the facility for at least 8 consecutive hours on 12/14/2025.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare and Medicaid Services (CMS). Staffing information for Quarter 4 (July 1 - September 30, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. *Infection surveillance for July 2025, did not include date of onset, criteria met, culture, results or treatment (if any) for every listed resident.*Infection surveillance for September 2025, did not include signs/symptoms, criteria met, date of onset, culture taken, resulted organism or date infection resolved for every resident listed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional standards for 1 of 2 medication refrigerators located in the medication room.*The North unit refrigerator, located in the medication room, did not have a temperature log to ensure proper temperature range.*R3's insulin vial was not stored in the medication refrigerator.

Inspectors wroteBased on interview and record review, the facility did not inform residents when changes in coverage was made from Medicare Part A to items and services offered by the facility for which the resident may be charged and the amount of charges for those services by providing the residents with a Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for 2 (R23 and R48) of 3 residents reviewed for requiring the NOMNC and SNF ABN to be provided.*R23 was not provided a SNF ABN prior to ending Medicare Part A coverage for services and the NOMNC was emailed to R23's Guardian with no verification of receipt.*R48 was not provided a SNF ABN prior to ending Medicare Part A coverage for services.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R9) of 6 resident's reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R9 and/or their representative received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R9 was transported and admitted to the hospital on [DATE]. There was no evidence of a transfer notice or bed hold policy being provided to R9 and or R9's representative.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R12) of 35 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being.* R12 has a diagnosis of vision loss. R12's care plan for impaired visual function did not include person-centered interventions to address R12's needs.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries for 1 (R1) of 4 residents reviewed for pressure injuries. R1's heels were observed to be directly on the mattress and not offloaded according to R1's plan of care.

Inspectors wroteBased on interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 (R30) resident reviewed for accidents.*R30 was observed self-transferring from R30's bed to wheelchair.

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R33) of 1 resident receiving oxygen therapy.*R33's oxygen was observed during the survey to be set at 4.5L (liter)/minute without humidification. R33's physician orders is for oxygen to be administered at 3L/minute.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication rate was below 5 percent in 1 (R5) of 5 residents observed receiving medications. The facility medication error rate was 12 percent.*R5 had medications that were not administered in the correct method per the facility policy and procedure and current standards of practice. ASMP Medication Safety Alert, Preventing errors when preparing and administering medications via enteral feeding tubes, November 17, 2022, Volume 27, Issue 23, . Wrong administration technique. Common inappropriate administration techniques include: 1) mixing multiple medications together to give at once.

Inspectors wroteBased on interview and record review, the facility did not ensure Pneumococcal immunizations were offered, or refused, as eligible to residents. This was observed for 1(R30) of 5 residents whose immunization records were reviewed.* R30 did not have documentation of the Influenza vaccine being offered and did not have risk versus benefits were offered after a refusal.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 1 (R30) of 5 residents reviewed for immunizations.*R30's medical record does not contain any documentation as to whether R19 was offered, received, or declined the COVID-19 immunization.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to protect residents from resident-to-resident abuse for five (Residents (R)1, R6, R19, R12 and R11) of 20 sampled residents. This failure had the potential to create an environment where other residents had the potential to be abused.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure reportable allegations of abuse were reported to the State Agency (SA) in a timely manner and failed to notify the police of the abuse allegation for three residents (Resident (R)5, R8 and R11) of five residents reviewed for abuse in the sample of 20.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to complete a thorough investigation of abuse allegations for three residents (Residents (R)1, R6, and R8) out of 20 sampled residents. The facility demonstrated their lack of knowledge in completing a thorough investigation, which had the potential to increase a resident's risk of abuse throughout the facility.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to revise the care plan for one resident [(R)4] of 20 after a change in the resident's medication self-administration status. This failure had the potential for the resident's need to be not known by nursing staff.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to inform a family member of care conferences and/or provide sufficient notice in advance of care conferences for one of three residents (Resident (R) 3) reviewed for care planning out of a total sample of 13. This had the potential to affect the family member's right to have input into the development of the resident's care plan.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide nail care to one of three residents (Resident (R) 12) reviewed for assistance with activities of daily living (ADLs). R12 had fingernails that extended approximately one-half inch beyond the tips of his fingers and required staff assistance in trimming them. This failure caused R12 to have unmet personal hygiene needs.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure pressure ulcer treatments were ordered and treatments provided for two of four residents (Resident (R) 12 and R2) reviewed for pressure ulcers out of a total sample of 13. This failure put R12 and R2 at risk for deterioration of their pressure ulcers.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of current standards of practice, the facility failed to ensure one of one resident (Resident (R) 3) reviewed for enteral feedings out of a total sample of 13 received appropriate care and services to prevent complications. This failure had the potential to cause increased risk of infection for R3.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were available for administration for two of three residents (Resident (R) 5 and R2) reviewed for medication availability out of a total sample of 13. R5 did not have pain medication available to treat pain and R2 did not receive cefepime, an antibiotic, for 22 hours after admission to the facility. This had the potential to cause uncontrolled pain for R5 and increased risk of infection complications for R2.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to serve food that was served at an appetizing temperature for one of three residents (Resident (R) 5) reviewed for food palatability out of a total sample of 13. This failure had the potential for R5 to have unmet nutritional needs.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to perform pressure ulcer treatments in a manner to prevent potential cross contamination for one of four residents (Resident (R) 12) reviewed for pressure ulcers out of a total sample of 13. Licensed Practical Nurse (LPN) 1 took the treatment cart into the resident's room while performing the treatment and placed unused supplies back into the cart after the treatment was performed. This placed any residents requiring treatments at risk for cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a plan of care was developed based on the findings of the comprehensive assessment for 1 (R11) of 1 resident reviewed for hearing loss. The facility did not develop a plan of care that addresses R11's hearing loss or interventions of wearing or the refusal of wearing hearing aids.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R52) of 3 residents were free from unnecessary psychotropic medications ordered on an as needed (PRN) basis. On 8/1/2024 R52 was prescribed Ativan (anti-anxiety medication) 0.5 mg every eight hours PRN without an end date.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 2 (R9 and R24) of 3 residents observed. Three medication errors were observed out of twenty-eight opportunities, for a total error rate of 10.71 %. * R9 was administered levothyroxine after breakfast and not on an empty stomach per medication guidelines and R9 was Administered Timolol Maleate eye drops after their manufacturers instructions of discarding them 4 weeks after opening. * R24 was administered 150 milligrams (MG) of Venlafaxine immediate release when she was ordered to have 150 MG of extended release Venlafaxine.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R24) was free of significant medication errors. * R24 was administered 150 milligrams (MG) of Venlafaxine immediate release when she was ordered to have 150 MG of extended release Venlafaxine.

Inspectors wroteBased on interviews and facility job description review, the facility failed to ensure a qualified full-time staff with the required certification and skill sets was employed to serve as Food Service Manger (FSM) for 52 of 53 census residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure two of two residents and their resident representatives (Resident (R)1 and R14) reviewed for facility initiated emergent hospital transfer, from a total sample of 32 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure physician orders were followed for three of five residents (Resident (R) 2, R30, R32) reviewed for weights, out of a sample of 32 residents. This failure could create a scenario where significant weight loss or gain is not recognized as no baseline weight was established.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 3 of 6 residents (R36, R8, R48) reviewed for accidents received adequate supervision and assistance devices to prevent residents from sustaining continued falls. * The facility did not complete a fall investigation for a second fall R36 sustained on 2/12/2023 and there was no root cause analysis completed for a fall that occurred on 4/27/2023. On 5/4/23, R36 was noted to have been drinking alcohol and exhibiting intoxicated type behaviors. On 5/4/23, R36 had a fall with a head injury, requiring staples. There was no indication the facility increased supervision and monitoring of R36 when R36 was noted with intoxicated type behaviors. There was no indication if care planned interventions were in place at the time of the fall. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure 4 (R48, R33, R36, R8) of 16 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. * Staff did not understand the 4/12/23 physician's order for R48 which documented may have 1 drink a day. One ounce liquor per drink. Maximum of three ounces within 2 hours in a 24 hour period. Hold liquor if [R48] appears to be intoxicated or impaired. As needed. Staff were not consistently following the order resulting in R48 receiving 3 times the amount ordered. * During wound care for R33, staff did not use soap for incontinence care prior to dressing change. * R36 was missing neurological checks for unwitnessed falls that occurred on 1/10/2023 and 3/10/2023. [...]

Inspectors wroteBased on record review and interview, the facility did not provide a bed hold notice upon transfer to the hospital as required for 1 (R1) of 4 residents reviewed for hospitalization. *R1 was hospitalized on [DATE]. The facility did not provide a bed hold notice for R1's hospitalization on 4/3/23.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with pressure injuries receives appropriate care, treatment, and preventative interventions to promote healing for 2 (R26 and R62) of 6 residents reviewed for pressure injuries. 1. R26 had a right gluteal pressure injury and is at high risk for pressure injuries. On 6/15/23 R26's sacral would reopened. Treatments were for the right gluteal fold, sacrum and a protective dressing was put in place for the right buttocks on Tuesdays, Thursdays and Saturdays. On 7/10/23 Surveyor observed R26 with 3 bandages dated 7/6/23 which should have been changed Saturday 7/8/23. Documentation showed missed wound treatments on 7/8/23. On 7/10/23, the facility changed the order to Mondays, Wednesdays and Fridays. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not provide adequate nutritional support to 1 of 2 residents reviewed for Nutrition. * R62 was admitted to the facility on [DATE]. The facility did not accurately conduct a baseline weight upon admission for R62 in accordance with their policy and procedure. The facility did not provide nutritional supplement for R62 per dietician recommendations.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure consistent communication for 1 (R20) of 1 Residents reviewed who receive dialysis services. R20 did not have communication forms between the Facility and Dialysis provider until April 1, 2023. On 7/10/23 R20 was observed waiting for pick up for dialysis. R20 had no communication paperwork to bring with her to the dialysis appointment. Additionally, the dialysis center is noted to not send communication paperwork back to the facility. There is inconsistent communication between the facility and the dialysis center.

Inspectors wroteBased on observation and interview the facility did not ensure 1 (R33) of 5 residents observed during wound treatment had the necessary hand hygiene performed. On 7/12/23 at 8:14 a.m. Surveyor observed pressure injury treatment performed on R33. RN K had missed opportunity for hand hygiene during the observation.