Sherrill House

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing a.) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's recommendations and b.) accurately implement a wound intervention of an air mattress for four Residents (#152, #32 , #4, and #5) out of a total sample of 33 residents. 1. For Resident #152, the facility failed to prevent an existing ankle wound that was present on admission to the facility from worsening from a Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed) pressure ulcer to a Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle) pressure ulcer by not assessing and monitoring the wound and not implementing physician orders for wound treatment.2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice was provided for one Resident (#4) out of a total sample of 33 residents. Specifically, the facility failed to provide interventions for pain management during wound care treatment, resulting in the Resident experiencing pain during the wound care.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that services provided met professional standards for 3 Residents (#146, #42, and #134), out of 33 total sampled residents. Specifically,1.) For Resident #146, the facility failed to notify the provider and obtain and implement Bumex (a diuretic medication) for a weight gain as ordered by the physician.2.) For Resident #42, the facility failed to (2a.) implement a functioning air mattress physician's order, (2b.) complete a wound treatment and dressing documentation in the Treatment Administration Record (TAR).3.) For Resident #134, the facility failed to ensure daily weights were obtained according to the physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements in two out of four medication carts observed. Specifically,1.) The facility failed to ensure medications with shortened expiry dates were dated once opened, according to manufacturer's guidelines.2.) The facility failed to ensure medications were stored in the original, labeled containers.

Inspectors wroteBased on observations, interviews, and record review the the facility failed to notify the physician of a significant change in the resident's physical status for two Residents (#152 and #146), out of 33 total sampled residents. Specifically,1. For Resident #152, the facility failed to notify the provider of an admission with a right ankle pressure injury resulting in delayed treatment and monitoring of the Resident, deterioration of the wound and management of worsening wound condition. 2. For Resident #146, the facility failed to notify the provider of need to implement Bumex (a diuretic medication) for weight gain, which could potentially indicate the clinical complication of fluid overload.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that, within 48 hours of admission, nursing developed and implemented baseline care plan with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs for one Resident (#152), out of a sample of 33 Residents. Specifically, the facility failed to initiate a baseline care plan to address a right ankle Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed, or an intact/ruptured serum-filled blister) pressure injury resulting in the development of a right ankle Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle, often with undermining and tunnelling) pressure injury.

Inspectors wroteBased on record review and interviews, the facility failed to identify and implement interventions for a significant weight loss for one Resident (#141) out of a total sample of 33 residents.

Inspectors wroteBased on interviews and record review, the facility failed to accurately document in the medical record for one Resident (#32) out of a total sample of 33 residents. Specifically, for Resident #32, the nurses inaccurately documented checking air mattress settings according to the Resident's weight per the physician's order.

Inspectors wroteBased on observations, record review and interview, 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 one Residents (#4) out of a total sample of 33 Residents. Specifically,1. For Resident #4 the facility failed to implement hand hygiene during a wound dressing treatment.2. The facility failed to adhere to contact precautions for Resident #4.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals and outcomes, that addressed his/her overall immediate care needs.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was alert, oriented and made his/her own health care decisions, the Facility failed to ensure that he/she was fully informed in advance and given information including the risk and benefits of psychotropic medications prior to their use, when Resident #1 was administered nine (9) doses of an antipsychotic medication by nursing, before obtaining his/her consent to administer the medication.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents, (Resident #1, #2, and #3), the facility failed to ensure that upon admission, that nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had been maintained on oxygen via nasal cannula while at the Hospital, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when despite Resident #1's continued need for oxygen, there was no physician order obtained for administration.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who upon admission, had Orthopedic recommendations for nursing to monitor his/her left wrist and cast, the Facility failed to ensure they maintained a complete and accurate medical record, when the Orthopedic recommendations were not transcribed by nursing onto his/her Treatment Administration Record (TAR), and therefore was no nursing documentation on the TAR to support nursing monitored Resident #1's left wrist/cast. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as last revised April 2008, indicated the following: -all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record -all observations, medications administered, services performed, etc. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 10/29/24, after Facility Administration was made aware of an allegation of physical abuse, that they reported the allegation to the Department of Public Health (DPH) within two hours as required, and was not reported to the DPH until 12/06/24 (more than a month after Administration was made aware of the allegation).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 10/29/24, after being made aware of an allegation that he/she had been physically abused by a staff member, they obtained and maintained evidence that a thorough investigation into the allegation had been completed and that a summary of their investigation findings was submitted to the Department of Public Health within five days, as required.

Inspectors wroteBased on observations and interviews, the facility failed to provide a dignified experience for the residents of the facility by 1) failing to provide a dignified dining experience for the residents on the first floor unit, 2) ensuring a staff member was not on the phone while providing care for one Resident (#129) and 3) ensuring staff members were not storing person items in the room of one Resident (#38), out of a total sample of 34 residents.

Inspectors wroteBased on observation and interview the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated food, that staff did not store personal food with resident food and ingredients, that dented cans were not accepted into storage/circulation and that staff did not directly handle ready-to-eat food with contaminated gloves.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that one Resident (#144) did not self-administer medications out of a total sample of 34 residents. Specifically, Resident #144 was observed with a card of pills left at bedside for self-administration without being assessed for self- administration.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one Resident's (#150) personal care choices were honored, out of a total sample of 34 residents. Specifically, the facility failed to provide showers for Resident #150 per his/her request and preference.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for one Resident (#71) out of a total sample of 34 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for two Residents (#83 and #101) out of a total sample of 34 residents. Specifically, the facility failed to provide assistance with self-feeding tasks during mealtimes.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for two Residents (#103 and #88), out of a total sample of 34 Residents. Specifically, Residents #103 and #88 the facility failed to ensure nursing consistently set his/her oxygen flow rate as ordered by the physician.

Inspectors wroteBased on observations record review and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#364) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to.) out of a total sample of 34 residents. Specifically, the facility failed to ensure clamps and pressure dressings were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1.) The facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in two out of four medication carts observed. 2.) The facility failed to properly secure medication carts on two of four units.

Inspectors wroteBased on observations and interviews, the facility failed to provide a palatable meal to the residents on the first floor unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to adhere to infection control standards of practice for one Resident (#23) out of a total sample of 34 residents. Specifically, for Resident #23 the facility failed to appropriately follow Enhanced Barrier Precautions (EBP: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other Residents within the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to adequately secure medications. Specifically: 1) For Resident #2 the facility failed to ensure his/her medications were secured and not left at his/her bedside. 2) The facility failed to ensure staff secured medication carts on two of four nursing units. 3) The facility ensured medications were not left unattended on the medication carts and expired medications were not available for administration.

Inspectors wroteBased on record review and interview, the facility failed to investigate an allegation of potential abuse for 1 Resident (#232) out of a total sample of 32 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications per the physicians order for one Resident (#2) out of a total of 32 sampled Residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the formula from an enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach), was infused as ordered for one Resident (#89) out of a total of 32 sampled Residents.