Sheridan Memorial Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from abuse and neglect of care needs for 1 (#1) of 3 sampled residents. The deficient practice resulted in the resident feeling worthless, anxious, confused, and feeling like she was being punished.

Inspectors wroteBased on interview and record review, the facility staff failed to use a gait belt when ambulating a resident, resulting in a minor injury, which was a skin tear with tendon exposure to the left fourth digit, requiring only nursing treatment for 1 (#4); and failed to evaluate and modify Interventions to prevent future falls for 3 (#s 2, 4, and 5) of 3 residents sampled for falls. These deficient practices contributed to continued falls for the residents and increased the risk of potential injuries. Findings Include:1. Review of a Facility-Reported Incident, dated 11/4/25, showed resident #4 fell while ambulating with staff member K. Resident #4 was using a rolling walker and was wearing supplemental oxygen. Staff member K turned her back on the resident, and the resident lost her balance, falling backward onto her bottom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a grievance policy which included information on how to file a grievance anonymously for 2 (#s 19 and 20) of 21 sampled residents; and failed to post the grievance officer's address and phone number in a prominent location. This deficient practice affected all who have the right to file a grievance anonymously and who to contact if they wish to file a grievance.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of the Medical Director's (or Designee's) attendance and participation for Quality Assurance and Performance Improvement (QAPI) meetings, which were at a minimum, required to be completed quarterly. The Medical Director had involvement in the oversight of the care and services, and ensuring services met professional standards for care, and provided oversight for the review and approval of policies and procedures. This failure could affect all residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to uphold proper infection prevention and control practices during medication administration for 3 (#s 2, 22, and 27) of 4 residents receiving medication.

Inspectors wroteBased on interview and record review, the facility failed to identify a resident's past history of trauma and failed to identify triggers to avoid re-traumatization for 1 (#5) of 21 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to promptly refer a resident with lost partial dentures to dental services for 1 (#11) of 21 sampled residents. The deficient practice caused the resident to go without his partial denture, and the resident had experienced a weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to safely use a sit-to-stand lift when transferring a resident, causing injuries to include fractured ribs, and the resident was hospitalized for further evaluation, for 1 (#26) of 4 sampled residents for accidents.

Inspectors wroteBased on interview and record review, the facility failed to recognize, identify, and call a physician for confirmation of a coumadin order not being discontinued or held, for a resident with a critical lab value, for 1 (#26) of 3 sampled residents on coumadin.

Inspectors wroteBased on interview and record review, the facility staff failed to include 1 (#14) of 16 sampled residents, in care plan meetings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify bilateral grab bars as a potential restraint, and did not complete a risk assessment, obtain a consent, or have restraint monitoring, for 1 (#10) of 16 sampled residents with bilateral grab bars in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist was monitoring a resident receiving an as needed psychotropic medication for an excessive duration for 1 (#8) of 16 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days unless there was provider documentation explaining the rationale for continuing the medication, for 1 (#8) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse within 24 hours of the incident, for 1 (#19) of 16 sampled residents for abuse reporting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopements resulting in a fall with injury for 1 (#1) out of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure storage of schedule II-V medications were in separately locked, permanently affixed compartments; ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates; and failed to remove expired items for disposal for one medication room and one medication cart.

Inspectors wroteBased on interview and record review, the facility staff failed to provide psychotropic consent forms explaining the risks and benefits to residents or family members for 6 (#s 17, 19, 20, 22, 28, and 30) of 8 sampled residents.

Inspectors wroteBased in interview and record review, facility staff failed to complete and report findings in a timely manner for investigations for 5 (#s 6, 13, 14, 17, and 28) of 5 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to protect all residents in the facility during an investigation of allegations of abuse for 6 (#s 1, 6, 12, 17, 20 and 28) of 6 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to develop a comprehensive care plan which addressed monitoring and interventions for a resident on an antiplatelet aggregate medication (Plavix) for 1 (#19) of 2 sampled residents. This deficient practice had the potential for more than minimal harm due to not having any monitoring or interventions in place for medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to prevent a pressure ulcer for 1 (#19) of 2 sampled residents. This deficient practice resulted in harm for the resident due to surgical intervention, ongoing dressing changes, and a MRSA infection in the wound.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to administer prescribed medication in accordance with the manufacturer's specifications, and within standards of practice for optimal therapeutic effect, for 1 (#22) of 5 sampled residents.