Sheridan Medical Lodge

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 24 residents (Resident #120) whose records were reviewed for comprehensive care plans. Resident #120's comprehensive care plan was not revised to resolve a care plan addressing an indwelling urinary catheter after the catheter was removed and the order for the catheter was discontinued. This facility failure placed the residents at risk of not having individual care needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain accurately documented medical records for 1 of 24 (Resident #70) residents reviewed for accurate medical records. The facility failed to revise Resident #70's comprehensive care plan addressing the administration of anti-anxiety medication after the medication order was discontinued. This placed residents at risk of inaccurate representation of their care.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 3 (Resident #76, Resident #80 and Resident #99) of 32 residents reviewed for resident assessments. The facility failed to accurately assess Resident #76, Resident #80, and Resident #99's CPAP/BiPAP-use. This failure placed the residents at risk for unmet care needs and/or decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 7 of 23 residents (Residents #39, #97, #115, #227, #231, #234, and #236) reviewed for care plans in that: 1. The facility failed to ensure Resident #39 had a care plan in place for urinary incontinence, mood state, activities, or dehydration/fluid maintenance triggered on the resident's CAA. 2. The facility failed to ensure Resident #97 had a care plan in place for cognitive loss/dementia, visual, urinary incontinence, psychosocial well-being, mood status, activities, falls, or nutritional status triggered on the resident's CAA. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 23 (Resident #3) resident's rooms observed for environmental conditions. The facility failed to ensure that Resident #3's floor was clean and sanitized. The facility's failure placed the residents at risk for diminished quality of life from environment not being kept clean.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 2 of 3 residents (Resident #'s 1 and 4) reviewed for plan of care revision. The facility failed to include in the care plan a right foot brace/pose brace for Resident #1. The facility failed to include in the care plan, Behavioral Interventions for Resident #4. This failure could place the residents at risk of decline in health status and unmet physical and psychosocial needs due to the staff and providers not having the most current information for the Resident's plan of care.

Inspectors wroteBased on observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3(Resident #1, Resident #5 and Resident #6) of 3 residents reviewed for infection control. techniques in that: 1. The facility failed to ensure the 200 hall CNA E washed or sanitized her hands in between rooms or between feeding the following: Resident #6 and entering room and setting up Resident #1's food tray; after setting up Resident #1's room tray CNA E left Resident #1's room to set up tray for Resident #5. 2. The facility failed to ensure that 200 hall CNA E sanitized her hands or donned gloves when touching Resident #5's potato. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a summary of the baseline care plan was provided to the resident and their representative for 5 of 12 residents (Resident #s 163, 165, 170, 173, and 182) reviewed for baseline care plans following admission into the facility for skilled nursing care services, in that: 1. Resident #163's baseline care plan was dated 10/16/23 and a summary had not been provided to her. 2. Resident #165's baseline care plan was dated 8/23/23 and a summary had not been provided to him. 3. Resident #170's baseline care plan was dated 10/13/23 and a summary had not been provided to him. 4. Resident #173's baseline care plan was dated 9/20/23 and a summary had not been provided to him or his representative. 5. Resident #182's baseline care plan was dated 10/13/23 and a summary had not been provided to her. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop the comprehensive care plan with the participation of the resident and the IDT for 2 of 12 residents (Residents #46 and #55) reviewed for care plans, in that: 1. Resident #46 was not invited to participate in her care plan conference. 2. Resident #55 was not invited to participate in her care plan conference. This facility failure placed the residents at risk for individual needs not being identified and addressed and decreased feelings of self-determination and psychosocial well-being within their living environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure discontinued medications were secured in 1 of 1 medication rooms reviewed for pharmacy services. ADON A failed to ensure that medications that had been discontinued were secure. This failure could place the residents who resided in the facility at risk of a drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary service personnel wore hair coverings in 1 of 1 kitchen reviewed for kitchen sanitation, in that: Dietary Aide F did not wear an appropriate hair restraint to cover his mustache while working in the kitchen. This failure placed the residents at risk for food borne illness and consumption of contaminated food.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment was completed within 14 calendar days following admission to the facility, excluding days absent from the facility for a temporary hospitalization, for 1 of 4 residents (Resident #165) whose records were reviewed for admission MDS assessments, in that: Resident #165 was initially admitted to the facility on [DATE] and was temporarily hospitalized from [DATE] to 10/03/2023. A comprehensive MDS assessment had not been completed for Resident #165. The facility's failure placed the resident at risk for health conditions and care needs not being identified and personal health and care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objective and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #173) whose care plans were reviewed, in that: Resident #173 had an order to use supplemental oxygen continuously. The resident's comprehensive care plan did not address the resident's use of oxygen and the care needs associated with the use of supplemental oxygen. This failure placed the resident at risk for not receiving supplemental oxygen therapy as ordered and needed.