Inspection Reports for
Sheridan Memorial Nursing Home
440 W Laurel Ave, Plentywood, MT, 59254
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
16% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Jul 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, trauma-informed care, dental services, quality assurance, and infection prevention and control practices at Sheridan Memorial Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to establish a grievance policy with anonymous filing options and proper posting of grievance officer contact information, failure to identify and address a resident's trauma history and triggers, failure to promptly refer a resident for dental services after loss of partial dentures, failure to maintain documentation of medical director attendance at QAPI meetings, and failure to uphold proper infection prevention practices during medication administration.
Deficiencies (5)
Failed to establish a grievance policy including anonymous filing and failed to post grievance officer's contact information.
Failed to identify a resident's past trauma history and triggers to avoid re-traumatization.
Failed to promptly refer a resident with lost partial dentures to dental services, resulting in weight loss.
Failed to maintain documentation of Medical Director's attendance and participation in QAPI meetings.
Failed to uphold proper infection prevention and control practices during medication administration for three residents.
Report Facts
Residents sampled: 21
Residents affected by grievance deficiency: 2
Residents affected by trauma-informed care deficiency: 1
Residents affected by dental services deficiency: 1
Residents affected by infection prevention deficiency: 3
Weight loss percentage: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grievance Officer | Staff members G, B, and F identified as grievance officers but no full names provided | |
| Nurse NF3 | Provided information on resident #5's trauma history | |
| Nurse NF1 | Reported on resident #11's missing partial dentures and weight loss | |
| Staff member B | Provided information on grievance process and QAPI meetings | |
| Staff member C | Medical provider attending QAPI meetings via video conferencing | |
| Staff member D | Provided information on grievance drop box and infection prevention training | |
| Staff member E | Discussed resident #5's PTSD diagnosis communication | |
| Staff member Q | Observed failing hand hygiene during medication administration | |
| Staff member F | Confirmed grievance officer contact information was not posted |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 30, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to an injury sustained by resident #26 during transfer using a sit-to-stand lift, and concerns about medication management involving Coumadin.
Complaint Details
The complaint investigation substantiated that resident #26 sustained rib fractures and a large hematoma due to improper use of a sit-to-stand lift. The investigation also found medication errors related to Coumadin management, including failure to hold the medication despite a critical INR level and failure to notify a physician.
Findings
The facility failed to safely use a sit-to-stand lift causing rib fractures and a large hematoma in resident #26, who was hospitalized. Additionally, the facility failed to recognize and act on a critical Coumadin lab value, resulting in medication errors and lack of physician notification.
Deficiencies (2)
Failure to safely use a sit-to-stand lift causing injuries including fractured ribs and hospitalization of resident #26.
Failure to recognize, identify, and call a physician for confirmation of a Coumadin order not being discontinued or held for resident #26 with a critical lab value.
Report Facts
Residents sampled: 4
Residents sampled: 3
INR level: 5.7
Hematoma size: 13.6 cm x 5.5 cm x 4.2 cm
Rib fractures: 2
Coumadin dosage: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member O | Demonstrated use of sit-to-stand lift and reported sling size issues related to resident #26's injury | |
| Staff member B | Reported rib fractures and hematoma from sit-to-stand lift use and discussed investigation findings | |
| Staff member F | Responsible for investigation of resident #26's injury and shared findings with staff | |
| Staff member C | Intended to hold Coumadin medication for resident #26 but error occurred in medication system | |
| Staff member P | Stopped use of sit-to-stand lift after injury and documented hospital report |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, use of restraints, medication management, and psychotropic medication use at Sheridan Memorial Nursing Home.
Findings
The facility was found deficient in allowing a resident to participate in care plan meetings, failure to identify bilateral grab bars as restraints and complete required assessments, failure to ensure pharmacist monitoring of psychotropic medication use, and failure to limit as needed psychotropic medications to 14 days without proper documentation.
Deficiencies (4)
Failed to include resident #14 in care plan meetings despite resident being cognitively intact.
Failed to identify bilateral grab bars as restraints and did not complete risk assessment, obtain consent, or monitor restraint for resident #10.
Failed to ensure pharmacist monitored as needed psychotropic medication for excessive duration for resident #8.
Failed to limit as needed psychotropic medications to 14 days unless provider documentation justified continuation for resident #8.
Report Facts
Residents sampled: 16
Residents affected: 1
Dates of medication administration: 2
Assessment reference date: Apr 11, 2024
Pharmacist review period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Interviewed about care plan meeting invitations and documentation | |
| NF3 | Interviewed about consent for bilateral grab bars | |
| Staff member B | Interviewed about bilateral grab bars and psychotropic medication monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of verbal abuse towards a resident.
Complaint Details
The complaint was substantiated as the facility failed to report an allegation of verbal abuse within the required 24-hour timeframe. The incident involved resident #19 and was reported late by five days.
Findings
The facility failed to report an allegation of verbal abuse within 24 hours as required. The incident occurred on 2023-10-05 but was not reported until 2023-10-10, five days late. Staff responsible for reporting could not explain the delay, and the facility's policy lacked clear reporting timelines.
Deficiencies (1)
Failed to timely report an allegation of verbal abuse within 24 hours of the incident.
Report Facts
Residents sampled: 16
Residents affected: 1
Days late reporting: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B responsible for submitting abuse allegations but unable to explain delay | ||
| Staff member F who was reported to regarding the incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent elopements, which resulted in a resident falling and sustaining injuries.
Complaint Details
The investigation was triggered by a complaint related to resident #1 eloping multiple times, including a serious fall on 5/29/24. The resident was restless, intermittently confused, and able to disable safety alarms. The facility lacked adequate supervision and effective safety measures to prevent elopement. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to prevent elopements by a restless resident who eloped multiple times, including an incident on 5/29/24 where the resident fell out of his wheelchair outside the building and sustained facial injuries. The facility's wander guard and roam alert systems were ineffective or disabled, and staff lacked a formal protocol for 1:1 supervision.
Deficiencies (1)
Failed to provide adequate supervision to prevent elopements resulting in a fall with injury for one resident.
Report Facts
Date of fall incident: May 29, 2024
Date of survey completion: Jun 11, 2024
Number of elopements documented: 2
Number of non-alcoholic beers allowed per day: 2
Delay time for door lock: 15
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 7, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure to obtain psychotropic medication consents, delayed reporting of abuse investigations, failure to protect residents during abuse investigations, inadequate care planning for medication side effects, pressure ulcer care deficiencies, medication administration errors, and improper medication storage.
Complaint Details
The visit was complaint-related, investigating allegations including failure to obtain psychotropic medication consents, delayed reporting of abuse investigations, failure to protect residents during abuse investigations, inadequate care planning, pressure ulcer care deficiencies, medication administration errors, and improper medication storage. Substantiation status is not explicitly stated.
Findings
The facility failed to obtain psychotropic consent forms for multiple residents, delayed reporting abuse investigation findings beyond required timelines, failed to protect residents during abuse investigations, did not develop comprehensive care plans for residents on certain medications, failed to prevent pressure ulcers resulting in harm, administered medications improperly affecting therapeutic effect, and did not ensure proper storage and labeling of medications including expired drugs and unsecured controlled substances.
Deficiencies (7)
Failure to provide psychotropic consent forms explaining risks and benefits for 6 of 8 sampled residents.
Failure to timely report findings of abuse investigations for 5 of 5 sampled residents.
Failure to protect residents during abuse investigations; staff member accused of abuse was not suspended.
Failure to develop a comprehensive care plan addressing monitoring and interventions for a resident on antiplatelet medication.
Failure to prevent pressure ulcer resulting in surgical intervention and MRSA infection for one resident.
Failure to administer levothyroxine medication according to manufacturer's specifications and standards of practice.
Failure to ensure proper storage of schedule II-V medications in locked compartments and removal of expired medications.
Report Facts
Residents affected: 6
Days delay in reporting abuse investigation: 48
Days delay in reporting abuse investigation: 12
Days delay in reporting abuse investigation: 22
Days delay in reporting abuse investigation: 20
Medication doses: 3
Medication doses: 2
Medication dose: 75
Medication dose: 80
Medication dose: 10
Medication dose: 5
Medication dose: 324
Medication dose: 300
Medication dose: 60
Medication dose: 88
Medication dose: 40
Medication dose: 25
Medication dose: 20
Medication dose: 650
Medication dose: 75
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