Inspection Reports for
Sheridan Memorial Nursing Home

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility lacked a grievance policy including anonymous filing and failed to post grievance officer contact information, leaving residents unaware of the grievance process.

F 0699 Provide care or services that was trauma informed and/or culturally competent: the facility failed to identify a resident's PTSD diagnosis and triggers, and the care plan lacked interventions to avoid re-traumatization.

F 0791 Provide or obtain dental services for each resident: the facility failed to promptly refer a resident with lost partial dentures to dental services, resulting in the resident going without dentures and experiencing weight loss.

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly: the facility failed to maintain documentation of the medical director's attendance and participation in required quarterly QAPI meetings.

F 0880 Provide and implement an infection prevention and control program: the facility staff failed to perform hand hygiene during medication administration for three residents, risking infection transmission.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to safely use a sit-to-stand lift for a resident, causing rib fractures and a large hematoma due to use of an improperly sized sling.

F 0760 Ensure that residents are free from significant medication errors: the facility failed to recognize and call a physician to clarify a Coumadin order that was not discontinued despite a critical lab value, resulting in continued administration of the medication.

F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care: the facility failed to include one resident in care plan meetings and did not document invitations to the resident.

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment: the facility failed to identify bilateral grab bars as restraints and did not complete required risk assessments, obtain consent, or monitor restraint use for one resident.

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: the facility failed to ensure the pharmacist monitored a resident's as needed psychotropic medication for excessive duration and did not notify the provider.

F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; limit PRN orders to necessary use and 14 days: the facility failed to limit as needed psychotropic medication use to 14 days without documented rationale for continuation for one resident.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an allegation of verbal abuse within 24 hours, submitting the initial report five days late.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to prevent elopements by a restless resident who fell and sustained facial injuries after exiting the building unsupervised.

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments: the facility failed to provide documented psychotropic medication consent forms for six sampled residents, including residents #17, #19, #20, #22, #28, and #30.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility delayed reporting investigation findings for five residents, with delays ranging from 12 to 48 days beyond the required five-day reporting period.

F 0610 Respond appropriately to all alleged violations: the facility failed to protect residents during abuse investigations by not suspending or adequately monitoring staff involved in allegations and did not fully investigate incidents or implement preventive interventions.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to include monitoring goals and interventions for side effects of antiplatelet medication (Plavix) in the care plan for resident #19.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to prevent a pressure ulcer for resident #19, resulting in surgical intervention and MRSA infection, and was unable to provide requested wound care documentation.

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to administer levothyroxine according to manufacturer's specifications by giving it concurrently with other medications that interfere with absorption for resident #22.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to store schedule II-V medications in separately locked compartments, had expired medications in the medication room and cart, and the medication room refrigerator lock was broken.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report investigation findings within five days for five residents, with delays ranging from 12 to 48 days.

F 0610 Respond appropriately to all alleged violations: the facility failed to protect all residents during abuse investigations, allowing a staff member accused of abuse to continue providing care to other residents and inadequately addressing multiple resident-to-resident abuse incidents.