Sheridan Village Nrsg & Rhb

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records that were readily accessible, containing complete and accurately documented diagnosis for one (R1) of seven (R2, R3, R4, R5, R6, R7) residents reviewed. Findings Include:R1 has diagnosis not limited to Quadriplegia, Acute Neurologic, Mood disorder due to known physiological condition, Neuromuscular dysfunction of bladder, Major depressive disorder, single episode, Elevated prostate specific antigen and Aphasia. Wound Management Detail Report document in part: Wound Observation History: Date/Time Observed Rash 12/31/25 09:11 PM Rash distribution: Distributed. Rash color: Red. Rash Texture: Firm. Rash Shape: Scattered. Rash Details: Itchy. Comments: [...]

Inspectors wroteBased on observation, interviews and records review, the facility failed to follow proper sanitation and food handling practices. This failure has the potential to affect all 178 residents receiving food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for residents with a known mental illness for four (R76, R110, R116, R152) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35 residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in one of five medication carts reviewed, b.) remove and discard expired enteral feedings located in one of four medication storage rooms reviewed, and c.) ensure medications were locked and secured while unattended. These failures have the potential to affect 59 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 05/27/2025, at 11:07 AM, surveyor and V11 (Licensed Practical Nurse/LPN) located on the 3rd floor of the facility at the medication cart. Surveyor observes the following: one open house stock medication bottle labeled Meclizine 12. 5mg inside of the medication cart. Meclizine medication observed with an expiration date labeled 02/2025. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to follow their policy to ensure call light is within reach for 1 (R86) out of 3 residents reviewed for call lights in a total sample of 35. Findings Include: On 05/27/2025, at 11:30 AM, surveyor observed R86's foot of the bed is by the call light switch. R86's call light string was hanging on the floor. R86 was unable to reach her call light. R86 stated she cannot find her call light. R86 stated that she asked the staff multiple times to place the call light switch by her head. On 05/27/2025, at 11:35 AM, surveyor asked V18 (Registered Nurse) to come to R86's room. V18 stated R86 is totally dependent and needs help getting out of bed out of bed. V18 stated that R86 needs help transferring to the wheelchair. Surveyor asked V18 if she could locate R86's call light. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that medications were refilled and readily available for 2 residents (R60, R96) out of 8 residents reviewed for controlled substance medications in a sample of 35. The facility also failed to b.) keep an accurate count of all narcotic medications for two (R55, R118) residents, c.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 12 out of 237 shifts. These failures have the potential to affect 61 residents residing in the facility. Findings Include: R60's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: [...]

Inspectors wroteBased on observations, interview and records review, the facility failed to discontinue or get an order to continue as needed psychotropic medications and failed to get psychotropic consent from Power of Attorney (POA) for one (R52) resident of seven reviewed in a total sample of 35

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for one (R1) out of four residents reviewed for medication administration in a total sample of 35 residents reviewed, resulting in a 7.69% error rate. Findings Include: On 05/28/2025, at 9:22 AM, surveyor located on the 4th floor of the facility with V11 (Licensed Practical Nurse/LPN) during a medication administration pass. V11 administers Acetaminophen 500 mg: 2 tablets by mouth to R1. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Acetaminophen 325 mg- 2 tablets by mouth every 6 hours as needed. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg: 1 tablet by mouth twice a day scheduled at 9:00 AM and 5:00 PM. [...]

Inspectors wroteBased on interview and record review, facility failed to follow their policy to offer, educate and receive consent for influenza and pneumococcal vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to offer, educate and receive consent for COVID-19 (corona virus) vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35.

Inspectors wroteBased on interview and record review the facility failed to report alleged abuse allegations to the proper authorities within the prescribed time frame for one [R1] of three [R3, R4] residents reviewed for abuse. Findings Include: R1 clinical record indicate the following: R1 is a thirty-nine-year-old admitted with medical diagnosis including but not limited to cerebral palsy, schizoaffective disorder, chronic obstructive pulmonary disease, morbid obesity, hypertensive heart disease, sleep apnea, psychosis, bipolar disorder, and mood affective disorder. R1's minimum data set brief interview indicates R1 is cognitive intact. R1's care plan: 12/23/24, R1 has persistent mental illness. [...]

Inspectors wroteBased on interviews and records review, the facility failed to assess and conduct investigations for allegations of physical abuse for one (R1) resident in a sample of three reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food in the walk-in cooler/freezer was labeled with a date indicating when the item was placed into the walk-in cooler/freezer. This failure has the potential to affect all 174 residents in the facility who are receiving an oral diet.

Inspectors wroteBased on observation, interviews and records reviewed, the facility failed to ensure residents on enhanced barrier precautions (EBP) had EBP signs posted at their rooms, that staff were using Personal Protective Equipment (PPE) when providing care for residents and that the residents' PPE bins were available and stocked. These failures affected 4 (R24, R43, R83, R165) residents and has the potential to affect all 174 residents in the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that the residents indwelling catheter drainage bag is covered. This failure affected one resident (R165) reviewed for dignity in the sample of 59 residents. Findings Include: R165's admission record includes diagnoses of malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. R165's (5/11/24) Minimum Data Set documented, in part Section C. Cognitive Patterns. BIMS (Brief Interview for Mental Status) score is 15. R165 is cognitively intact. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. On 6/23/24 at 10:40 am, R165 indwelling catheter drainage bag was hanging from the bed frame facing the hallway not covered with a privacy bag. [...]

Inspectors wroteBased on interview and record review, the facility failed to rescreen a resident to determine if specialized services under the Preadmission Screening and Resident Review requirements are necessary. This failure affected 1 (R153) resident reviewed for PASRR screening in the total sample of 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean and correctly log refrigerator temperatures for one resident's (R135) personal refrigerator.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's adaptive equipment was functional. This failure affected 1 (R68) resident reviewed for adaptive equipment in the total sample of 59 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision to prevent a fall during incontinence care for one (R1) of three residents (R1, R3 and R4) reviewed for falls. This failure resulted in a fall by R1 who sustained a laceration on the forehead and was sent to the hospital emergency room receiving stitches to repair the laceration.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately supervise one resident (R3). This failure affected 1 resident (R3) causing R3 to sustain a right eyebrow laceration with one suture to R3's face.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the treatment cart was safely locked up when not in the vicinity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all 28 residents residing on the 2nd floor of the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident environment remains free of accidental hazards and the environment is free of sharp objects that could harm the residents. This failure affected R5 and R18 who has sharps stored on their bed side table and has the potential to affect all 31 residents residing on the 4th floor of the facility.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow their policy to ensure correct food temperatures were maintained prior to delivering food to residents for three (R1, R3, R4) out of three residents reviewed for dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing coverage per their assessed staffing needs to ensure adequate care and support. This failure has the potential to affect all 176 residents that reside in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow their abuse policy to protect residents from physical and verbal abuse for three (R1, R5, R11) residents reviewed for abuse in a sample of six.

Inspectors wroteBased on interviews and records review, the facility failed to follow their policy for Misappropriation of Resident Property and Exploitation. This failure resulted in three (R6, R7, R8) residents' being exploited by V11 (Former Certified Nursing Assistant), who took/borrowed their money, and did not buy them stuff or refund them their money as promised.

Inspectors wroteBased on the interviews and records review, the facility failed to report and initiate an investigation of alleged abuse in a timely manner by failing to identify and ensure the reporting of a suspected abuse. This failure affected 2 residents (R1, R2) out of 3 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement their Involuntary Transfer and Discharge Process policy and failed to provide their bed hold policy upon discharge to hospital for one of one resident (R1), reviewed for involuntary discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide their bed hold policy upon discharge to hospital for one (R1) of one resident reviewed for discharge.

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one resident (R1) of one reviewed for discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper food storage practices and label/date food items; failed to ensure staff's personal food items were not stored in the kitchen; failed to ensure the cleanliness of the stand-alone freezer; and failed to follow proper sanitation guidelines to prevent foodborne illness. These failures have the potential to affect all 173 residents receiving a meal tray from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that facility staff receive behavioral health training to safely and effectively respond to residents' behaviors and failed to have a process in place to track staff's participation in the training. These failures have the potential to affect all 124 residents in the facility who have diagnoses of SMI (Serious Mental Illness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the walls and base boards of the fourth-floor dayroom, shower room, and hallway in good repair. This failure has the potential to affect all 29 residents on the fourth floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident's (R139) urinary catheter drainage bag was covered with a privacy cover and failed to provide dignity for one resident (R158) who was accused by facility staff of stealing in the presence of other residents, resulting in R158 feeling humiliated. These failures affected two residents (R139 and R158) in a sample of 58 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and functional homelike environment for one resident (R76) out of 7 residents reviewed in the total sample of 58 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that an accurate Community Access Observation was complete for one resident (R45), who was reviewed for timely and accurate assessments. This failure has the potential to affect all residents that reside at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to check placement of the Gastrostomy tube (G-tube), failed to check residual amount of enteral formula and failed to administer medications in accordance with Professional Standards for one resident R26. This failure affected one resident (R26) out of a sample 5 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen tubing per the facility policy. This failure affected one resident (R46) reviewed for oxygen equipment, in a total sample of 58 residents.