Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheridan Memorial Nursing Home during CMS and state inspections, most recent first.
A resident was kept in a recliner in a common lounge instead of being allowed to remain in bed, despite requesting to return to bed, and was described by staff as unusually anxious and distraught. During night shift, staff told the resident she would not receive water because she would need to get up to use the bathroom, and the resident reported being told not to use the call light, being refused an ice pack, and having no way to summon help. Day-shift staff observed the resident without water nearby and heard night-shift staff state in front of the resident that she did not get water because she would need to get up. Facility investigative notes indicated the resident’s walker was moved farther away, her request to return to bed was dismissed, and she reported feeling punished and worthless, leading the facility to determine the incident met the definition of abuse under its abuse policy.
Staff failed to use a gait belt while assisting a resident who was ambulating with a rolling walker and on supplemental O2, then turned away from the resident, resulting in a backward fall and a skin tear with tendon exposure to a finger. The same resident had multiple additional unwitnessed falls and a near miss related to ambulation and oxygen tubing. Two other residents with repeated unwitnessed falls, including one with Parkinson-related freezing and another with weakness, confusion, tremors, and sepsis onset, had numerous fall events discussed in weekly fall meetings, but their fall care plans were not updated to reflect the interventions identified. Staff interviews confirmed expectations for gait belt use and individualized gait belts, and revealed that care plans were not being revised after fall meetings despite a facility fall-prevention policy allowing addition of interventions to care plans.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient oversight in the area.
The facility did not have a grievance policy that included instructions for anonymous submissions and failed to post the grievance officer's contact information. Two residents were unaware of how to file grievances or where to find forms, and staff handled concerns verbally without documentation. The available drop box was labeled for suggestions, not grievances, and the written policy lacked guidance on anonymous submissions.
The facility did not maintain required documentation showing the Medical Director or designee's attendance at QAPI meetings, as only one instance of attendance was recorded over several months. Staff confirmed that meetings occurred and that the Medical Director or designee sometimes participated via video conferencing, but there were no sign-in sheets or consistent records to verify this, resulting in a failure to meet regulatory requirements for QAPI committee documentation.
Staff failed to perform required hand hygiene before and during medication administration for multiple residents, including handling dropped medication and touching various surfaces and resident items without sanitizing hands or equipment, contrary to facility policy and infection control standards.
A resident with chronic atrial fibrillation and on Coumadin therapy returned from the hospital with a critically elevated INR and a large hematoma. Despite hospital instructions to hold Coumadin, the medication was continued in the LTC facility due to a communication breakdown and lack of nursing follow-up, resulting in the resident receiving unnecessary doses. Staff did not question the order or notify the provider as required by facility policy.
A resident with a documented history of PTSD and significant past trauma did not have their diagnosis, triggers, or appropriate interventions identified in their care plan. Staff were aware of the resident's trauma history and triggers but lacked a process to communicate this information, and the resident's MDS assessment did not reflect the PTSD diagnosis. No trauma-informed care assessment or social history was available, resulting in a failure to provide trauma-informed and culturally competent care.
A resident with severe cognitive impairment and on a pureed diet lost his upper partial denture, and the facility did not promptly refer him to dental services or offer a replacement. The resident experienced significant weight loss, and staff interviews revealed a lack of awareness and documentation regarding the missing denture.
A facility failed to report an allegation of verbal abuse by a staff member towards a resident within the required 24-hour timeframe. The incident was reported internally on the day it occurred but was not submitted to the State Survey Agency until five days later. The staff member responsible for reporting could not explain the delay, and the facility's policy lacked specific reporting timelines.
A resident was not included in care plan meetings, despite being cognitively intact and expressing a desire to participate. The resident's electronic medical record lacked documentation of invitations to these meetings. A staff member confirmed that while family members were contacted, the resident was not invited, and no documentation of such invitations was maintained.
A facility failed to identify bilateral grab bars as a potential restraint for a resident, neglecting to complete a risk assessment, obtain consent, or implement restraint monitoring. Observations showed grab bars on the resident's bed, and interviews indicated possible consent due to the resident's fall history. However, the medical record lacked necessary documentation, and staff noted the grab bars were not used as assistive devices. The facility's policy stated restraints would not be used for convenience.
A facility failed to ensure a pharmacist monitored a resident's as needed psychotropic medication for excessive duration. The resident received lorazepam for over 14 days without the pharmacist addressing the issue with the medical provider, contrary to facility policy. A staff member was unaware of the prolonged order, highlighting a lapse in monitoring and communication.
A facility failed to limit a resident's PRN lorazepam order to 14 days without documented rationale from a provider. The resident's MAR showed lorazepam was administered twice, but the order remained active beyond the 14-day limit. A staff member was unaware of the ongoing order, and the pharmacist did not identify or address the issue during medication regimen reviews. The facility's policy required PRN psychotropic orders to be limited to 14 days and used only for specific, documented circumstances.
A resident with a history of elopement and confusion managed to leave the facility unsupervised, resulting in a fall and facial injuries. Despite staff efforts to redirect him, the resident exited the building by catching the main door before it latched. The facility's Roam Alert System was unreliable, and staff had become desensitized to its alarms. The resident's care plan included interventions for his elopement risk, but these were insufficient to prevent the incident.
Resident Kept in Recliner, Denied Water and Call Light, Resulting in Abuse Finding
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and neglect of care needs when the resident was forced to remain in a recliner in a day lounge, denied water upon request, and left without access to a call light or other means to summon help. A facility-reported incident documented that the resident reported being kept in an uncomfortable recliner in a common area instead of in bed, being told she could not have water because she would need to get up to use the bathroom, and not being allowed to use her call light. The resident repeatedly expressed feeling as if she was being punished and reported feeling as though she was not worth anything due to the way she was treated during the night shift. Staff interviews and written statements corroborated key aspects of the resident’s account. When day-shift staff arrived, they found the resident in a recliner in the day lounge, which was unusual because she was typically in bed at the start of the day shift. One staff member reported that, during hand-off report, the night-shift staff member stated in front of the resident and other staff that the resident did not get any water because she would need to get up, and that there was no water near the resident. Staff also reported that the resident stated her call light had not been answered during the night, that she had been told not to call for help, and that she was refused an ice pack. The resident appeared distraught, anxious, and repeatedly questioned why she had been treated that way, requiring frequent reassurance from day-shift staff. The facility’s investigative documentation further detailed that the resident reported being denied water, being told she could not have her call light, and being kept in an “awful” room in an uncomfortable chair. Staff statements indicated that the night-shift staff member moved the resident to the day lounge after the resident got up multiple times without using her call light, purportedly to keep an eye on her. Abuse meeting notes identified concerns that the resident was placed in a recliner in a common area despite asking to return to bed, that this request was dismissed, that an overbed table may have been placed across her to keep her in the recliner, that her walker was moved farther away to limit mobility, and that the resident reported feeling punished. These actions and omissions were determined by the facility’s internal review to constitute abuse under the facility’s abuse policy, which states that each resident has the right to be free from abuse and that the facility is responsible to prevent abuse and neglect.
Failure to Use Gait Belt and Update Fall Care Plans After Repeated Falls
Penalty
Summary
Facility staff failed to ensure safe ambulation practices and adequate supervision, and did not consistently evaluate and modify fall-prevention interventions. In one incident, a resident ambulating with a rolling walker and on supplemental oxygen fell when the assisting staff member turned her back on the resident. The resident was not wearing a gait belt at the time, contrary to facility policy and staff expectations that gait belts be used for all residents requiring assistance with transfers or ambulation. The resident fell backward onto her bottom, struck her left arm and hand on a door jamb, and sustained a skin tear with tendon exposure on the left fourth finger that required nursing treatment. The same resident had multiple additional unwitnessed falls and a near miss over several months. One nursing progress note documented that the resident was ambulating in the hallway while still connected to an oxygen concentrator in her room, tripped on the oxygen tubing, and nearly fell but was caught by a CNA. A list of falls showed several unwitnessed falls and a near miss, indicating repeated events without documented evidence in this report of effective modification of interventions specific to those incidents. Staff interviews confirmed that gait belts were expected for assisted ambulation and that each resident should have their own gait belt, yet staff could not explain why a gait belt was not used during the documented fall. For two other residents with multiple unwitnessed falls, the facility did not update fall care plans to reflect new or revised interventions discussed in weekly fall meetings. One resident experienced numerous unwitnessed falls in her room, bathroom, and another resident’s room, with documented causes such as unsafe gait, dehydration, increased weakness and confusion, new medication, tremors, and sepsis onset. Fall meeting notes listed various potential or actual interventions, including walker use, room changes, supervision, and use of a gait belt, but the fall care plan showed only the later addition of a gait belt and no other changes over several months. Another resident, assessed as high risk for falls and with Parkinson-related freezing, had multiple unwitnessed falls in the bathroom, by the bed, and between a recliner and bed. Fall meeting notes documented causes such as not calling for staff and resistance to asking for help, with suggested interventions like hourly rounding, ensuring wheelchair positioning and locking, and attempting a toileting schedule. However, the fall care plan showed no changes after these events, and staff acknowledged they had not been updating care plans following weekly fall meetings, despite a facility fall-prevention policy stating that interventions may be added to care plans to prevent further falls.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Accessible and Anonymous Grievance Process
Penalty
Summary
The facility failed to establish and implement a grievance policy that included instructions for submitting grievances anonymously and did not post the grievance officer's contact information in a prominent location. Two residents reported being unaware of the grievance process, how to file grievances anonymously, or where to find or deposit grievance forms. Observations confirmed the absence of posted information identifying the grievance officer and the required contact details. Additionally, the box available for submitting forms was labeled for 'Suggestions' rather than grievances or complaints, and had previously been repurposed, further contributing to confusion. Interviews with staff revealed that the grievance officer had not processed any resident grievances and that concerns were typically handled verbally without documentation. Staff indicated that residents would need to request a grievance form, which was only available electronically and required staff assistance to print. The facility's written policy on complaints and grievances did not include procedures for anonymous submissions. These actions and omissions resulted in a lack of accessible and clear grievance procedures for residents.
Lack of Documentation for Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to maintain proper documentation of the Medical Director's or designee's attendance and participation in Quality Assurance and Performance Improvement (QAPI) meetings, which are required to occur at least quarterly. Record review revealed that, except for one documented instance in April 2025, there was no evidence of a medical provider or director attending QAPI meetings from September 2024 to March 2025, and from May 2025 to July 2025. Staff interviews confirmed that while QAPI meetings were held monthly (excluding July and December), there were no sign-in sheets to verify attendance, and the facility relied on meeting minutes to record attendees. Staff also indicated that the Medical Director or designee sometimes attended via video conferencing, but this was not consistently documented. The facility's QAPI policy requires the Medical Director to be a member of the committee and for meetings to occur at least quarterly. Despite requests for sign-in documentation to confirm the Medical Director or designee's attendance at required meetings, no such records were provided during the survey. This lack of documentation means the facility could not demonstrate compliance with regulatory requirements for QAPI committee composition and meeting frequency.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control practices during medication administration for three of four observed residents. Specifically, a staff member did not perform hand hygiene prior to handling or administering medications to multiple residents. In one instance, a medication was dropped onto the medication cart surface, picked up with a plastic spoon, and placed in a medication cup without hand hygiene being performed or the cart surface being sanitized. Additionally, the staff member was observed touching various surfaces and resident items, such as a call light, water cup, and the resident's hand, without performing hand hygiene before administering medications. Interviews with staff confirmed awareness that hand hygiene should occur before and after resident contact, but review of facility training materials revealed no specific training on infection prevention during medication administration. Facility policies on medication administration and hand hygiene require handwashing before medication preparation and administration, and after contact with inanimate objects or glove use, but these procedures were not followed during the observed incidents.
Failure to Hold Anticoagulant After Critical Lab Value Due to Communication Breakdown
Penalty
Summary
The facility failed to recognize, identify, and confirm with a physician the need to discontinue or hold a Coumadin (warfarin) order for a resident who had a critical lab value. The resident, who had chronic atrial fibrillation and was on chronic anticoagulation therapy, returned from the emergency department with a significantly elevated INR and a large hematoma. Despite documentation in the hospital records to hold Coumadin for one week due to the elevated INR, the medication orders in the long-term care facility's electronic medical record remained unchanged, and the resident continued to receive the medication. Nursing staff did not question the continuation of Coumadin, nor did they contact the provider for clarification, even though the facility's policy required provider notification and holding the medication for elevated INR levels. Interviews with staff revealed a communication breakdown between the hospital and the LTC facility, resulting in the hold order not being transferred to the facility's EMR. Staff acknowledged that critical thinking and nursing judgment were not applied, and the Coumadin order was not included in the investigation of the resident's injury, which was attributed to the use of the sit-to-stand lift and the effects of anticoagulation. The facility's policy required prompt provider notification and action for elevated INR, which was not followed in this case.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address a resident's history of trauma and associated triggers, resulting in a lack of trauma-informed and culturally competent care. The resident had a documented diagnosis of chronic post-traumatic stress disorder (PTSD), with provider notes indicating ongoing treatment and medication adjustments for PTSD and depression. Interviews revealed the resident had a significant trauma history, including an abusive marriage, the loss of a child, and childhood hospitalization. Staff acknowledged that the resident experienced triggers, such as believing her ex-husband was present at the facility, but there was no recent discussion of her PTSD diagnosis among staff due to staff turnover. Review of the resident's care plan showed it did not include the PTSD diagnosis, nor did it identify specific triggers or interventions to prevent re-traumatization. The resident's Minimum Data Set (MDS) assessment did not indicate PTSD as an active diagnosis, and no trauma-informed care assessment or social history was provided upon request. Staff interviews confirmed there was no process to ensure communication of specialized provider diagnoses to staff, contributing to the lack of trauma-informed care planning for the resident.
Failure to Refer Resident for Replacement of Lost Dentures
Penalty
Summary
The facility failed to promptly refer a resident with lost partial dentures to dental services, resulting in the resident going without his upper partial denture. The resident, who had Alzheimer's disease and severe cognitive loss, was on a pureed diet and expressed dislike for the texture. The loss of the partial denture was discovered when the resident's family came to pick him up for a home visit, and staff informed them that the denture was missing. Documentation showed that the denture was reported missing, and a search was conducted, but there was no evidence that a referral to dental services was made or that replacement was offered. Review of the resident's records indicated a significant weight loss of 15% over six months. The facility's policy stated that it is responsible for lost dentures when the resident is not competent or has dementia. However, staff interviews revealed that some were unaware the denture was missing, and no documentation was provided to show follow-up or referral to dental services before the end of the survey.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 24-hour timeframe. The incident involved a staff member allegedly verbally abusing a resident before 8:00 a.m. on October 5, 2023, and was reported internally to another staff member at 11:30 a.m. the same day. However, the initial report to the State Survey Agency was not submitted until October 10, 2023, five days after the incident occurred. During an interview, the staff member responsible for submitting abuse allegations to the state was unable to explain the delay, despite being aware of the required reporting timelines. Additionally, the facility's abuse policy, dated August 27, 2023, did not specify the reporting timelines for incidents to the State Survey Agency.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility staff failed to include a resident in care plan meetings, which is a deficiency in allowing residents to participate in the development and implementation of their person-centered plan of care. During an interview, the resident expressed that she was not invited to any care plan meetings, although her family members were. The resident indicated a desire to attend these meetings. A review of the resident's electronic medical record showed no documentation of her being invited to participate in her care plan meetings. The resident was assessed as cognitively intact with a score of 13 on the Brief Interview for Mental Status. A staff member responsible for inviting participants to care plan meetings confirmed that she contacts family members but does not document these invitations and acknowledged that the resident had not been invited to her care plan meetings.
Failure to Identify and Document Bilateral Grab Bars as Restraints
Penalty
Summary
The facility failed to identify bilateral grab bars as a potential restraint for a resident and did not complete necessary procedures such as a risk assessment, obtaining consent, or implementing restraint monitoring. During observations, bilateral grab bars were noted on the resident's bed. An interview revealed that consent might have been given due to the resident's history of falling out of bed and sustaining bruises, as well as undergoing head scans due to falls. However, the resident's electronic medical record lacked documentation of a risk assessment, physician's order, or signed consent for the use of the grab bars. The resident was assessed as dependent for turning and repositioning, and staff indicated that the grab bars were not used as an assistive device but rather for hanging the call light and bed controls. The facility's restraint policy stated that restraints would not be used for convenience.
Pharmacist Fails to Monitor Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a proper monthly drug regimen review for a resident receiving as needed psychotropic medication. Specifically, the pharmacist did not monitor a resident who was receiving lorazepam for an excessive duration. The resident's Medication Administration Record (MAR) indicated that lorazepam was administered on two occasions, and the order for this medication had been in place for more than 14 days. During an interview, a staff member was unaware of the prolonged order and noted that the pharmacist had not addressed this issue with the medical provider. The facility's policy required the pharmacist to monitor psychotropic medication use and notify the physician when a review was due, which was not adhered to in this case.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days unless there was provider documentation explaining the rationale for continuing the medication. This deficiency was identified for one resident who had an order for lorazepam, to be taken twice a day as needed for anxiety or shortness of breath. The resident's medication administration record (MAR) showed that lorazepam was administered on two occasions, but the order for the medication remained active beyond the 14-day limit without documented justification from a medical provider. During an interview, a staff member acknowledged being unaware of the ongoing order for as-needed lorazepam beyond the 14-day period. The responsibility for monitoring such orders was attributed to the medication nurse or care coordination nurse. Additionally, the facility's medication regimen reviews, conducted by the pharmacist, failed to identify the prolonged as-needed use of lorazepam, and there was no evidence that the pharmacist contacted the provider to address this issue. The facility's policy on psychotropic medications clearly stated that as-needed orders should be limited to 14 days and used only for specific, documented circumstances.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, resulting in a fall with injury. The resident, who had a history of elopement and periods of confusion, managed to leave the facility without staff awareness. On the day of the incident, the resident was restless and attempted to access the elevator multiple times. Despite staff efforts to redirect him, he successfully exited the building by catching the main door before it latched, leading to a fall in the street where he sustained facial injuries. The resident had a history of elopement, often leaving for the hospital connected to the facility. Staff interviews revealed that the resident was known to be restless and had learned to disable the door alarm system. The facility's Roam Alert System, intended to prevent such incidents, was reportedly unreliable, and staff had become desensitized to its alarms. The resident's elopement risk was documented, but the facility did not foresee his ability to exit the building until the incident occurred. Interviews with staff indicated a lack of clear protocol for 1:1 supervision, which was left to the discretion of the nurse on shift. The resident's care plan acknowledged his elopement risk and included interventions such as a new wander guard system and offering non-alcoholic beers to address his restlessness. However, these measures were insufficient to prevent the elopement and subsequent injury.
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