Civita Care Sheriden Woods

In the surveyor’s words

From the most serious findings on record at Civita Care Sheriden Woods, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 13, 2026

  Based on review of the clinical record, facility documentation/policy, and staff interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision was provided to prevent an accident for a resident identified as cognitively impaired and at risk for falls. Specifically, the facility failed to ensure Resident #1 was supervised during bedside urinal use when left out of staff line of sight behind a privacy curtain, resulting in a fall with injury. […]

• Actual harm, isolatedF689Jan 30, 2026

  Based on review of Resident #1's clinical records (including Minimum Data Set assessments, care plan, admission documentation, and nursing notes), facility policies, and staff interviews, the facility failed to ensure the resident, who required two-person assistance for transfers as per the care card, was transferred per protocol on 1/16/2026. As a result, Resident #1 sustained an acute comminuted fracture of the left distal femoral shaft above the knee, confirmed by X-ray and hospital records. This constitutes a preventable accident, reflecting a breakdown in supervision and adherence to established protocols. […]

• Actual harm, isolatedF600Mar 31, 2023

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure Resident #1 was free from mistreatment. The findings include: Resident #1's diagnoses included Alzheimer's disease, diabetes mellitus, chronic kidney disease, major depression, anxiety disorder and difficulty in walking with unsteadiness. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition, required limited assistance for bed mobility and transfers, extensive assistance for dressing, toileting, and personal hygiene, was at risk for skin breakdown and was frequently incontinent of urine, and occasionally incontinent of bowel. […]

• Actual harm, isolatedF686Dec 9, 2021

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #128) reviewed for catheter use, the facility failed to ensure the resident did not develop a pressure area related to the catheter use. The findings include: Residents #128's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] identified Resident #128 had moderately impaired cognition, had an indwelling catheter, and had no pressure ulcers. The Resident Care Plan (RCP) dated 7/30/2021 identified Resident #128 was at risk for skin breakdown and had a foley catheter. […]

• Actual harm, isolatedF689Dec 9, 2021

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #40) reviewed for accidents, the facility failed to ensure supervision was provided for a dependent resident to prevent a fall with injury. The findings include: Resident #40's diagnoses included Alzheimer's and a history of repeated falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #40 had severe cognitive impairment, was frequently incontinent of bowel and bladder, required extensive assistance of one (1) staff for toilet use and transfers, used a walker, and had three falls since 12/17/2020 (two of the falls were with injury). […]