Complete Care at Sheriden Commons

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 15, 2024

  Based on interview and record review, the facility failed to identify and treat the cause of new pain in left arm; failed to timely review x-ray results; failed to relay x-ray results to physician; failed to obtain verbal or telephone order from physician for pain patch for one resident (R4) in a total sample of 3 residents (R4, R5, and R6). These deficient practices resulted in harm for R4 experiencing new onset left arm pain for 34 days with limited mobility due to a left humerus fracture diagnosed at an outside hospital. Findings include: On 08/13/24 at 12:48pm V19 Medical Doctor (MD) stated, R4 came to the emergency room (ER) unable to move his (R4) left arm and was found to have a subacute fracture to the left humerus. […]

• Actual harm, isolatedF692Aug 15, 2024

  Based on interview and record review the facility failed to properly assess and manage oral fluid intake, urinary output and bowel output in a resident (R4) who was at risk for dehydration. This deficient practice resulted in harm for one resident (R4) requiring hospitalization for acute kidney disease and fecal impaction. Finding include: R4's diagnosis includes but are not limited to Major depressive disorder, Chronic respiratory failure, Chronic obstructive pulmonary disease, Morbid obesity, Venous insufficiency, Sleep Apnea. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 13 which indicates R4's cognition is intact. […]

• Actual harm, isolatedF684Mar 16, 2023

  Based on interview and record review, the facility failed to provide ice for a resident's orthopedic cold therapy ice machine used for pain and swelling and failed to timely provide and administer a controlled substance seizure medication to a resident which affected one resident (R1) of four residents (R1, R2, R3, and R4) reviewed for improper nursing care and resident rights. This failure resulted in R1 experiencing a seizure and emergently being sent to the hospital. Findings include: R1's Admission Record, documents, in part, that R1's diagnoses include encounter for other orthopedic aftercare, epilepsy, lack of coordination, difficulty in walking and unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing. […]

• Actual harm, isolatedF689Mar 16, 2023

  Based on interview and record review, the facility failed to provide adequate supervision to a resident who was assessed as a high fall risk which resulted in a fall. This failure affected one resident (R2) of three residents (R2, R3, R4) reviewed for falls in the facility. Findings include: R2's Admission Record, documents, in part, that R2's diagnoses include encephalopathy, epilepsy, contracture of muscle, unsteadiness on feet, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2's Brief Interview for Mental Status (BIMS) score is a 12 which indicates that R2 is has moderate cognitive impairment. […]

• Actual harm, isolatedF684Sep 20, 2022

  Based on interview and record review, the facility staff failed to ensure that a resident got timely transportation to follow up with the surgeon for adequate post-operative care and failed to notify the physician of resident's change in condition of the surgical wound. These failures affected one resident(R1), who missed two scheduled post-operative appointments with the surgeon, and it resulted in infection and dehiscence of the surgical site on R1's left above-the-knee-amputation (AKA) stump. At the hospital, R1 was diagnosed with AKA Stump Complication, as one of the diagnoses. […]