Majestic Care of Sheridan

In the surveyor’s words

From the most serious findings on record at Majestic Care of Sheridan, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 27, 2021

  Based on observation, record review and interview, the facility failed to prevent an avoidable accident when 2 staff members did not use a mechanical lift to transfer a resident from a wheelchair to a bed and failed to have a Physical Therapy (PT) evaluation completed before determining the resident was safe to transfer with the assistance of 2 staff members and a gait belt for 1 of 3 residents reviewed for accident hazards. (Resident B) This resulted in harm when Resident B had a fall which resulted in a lower extremity fracture requiring hospitalization and surgery. Finding include: During an observation of the facility, on 01/27/2021 at 3:30 p.m., Resident B was observed in her bed. […]

• No harm, potential for more than minimal, widespreadF812Jan 11, 2023

  Based on observation, interview and record review, the facility failed to label, date and store refrigerated and freezer foods, failed to prevent freezer burn, failed to date canned items when received, failed to date frozen meats when placed in the refrigerator to thaw, and failed to serve food in a sanitary manor. This deficient practice had the potential to effect 78 of 78 residents who received food from the kitchen. Findings include: During a kitchen observation, on 01/04/23 at 9:23 a.m., with the Kitchen Manager present the following was observed: 1. In the dairy refrigerator: a. A large bag of shredded cheese was open, unsealed without an open date. b. 15 hot dogs were open, unsealed without an open date. 2. In the meat freezer: a. […]

• No harm, potential for more than minimal, isolatedF580Apr 10, 2026

  Based on interview and record review, the facility failed to ensure the physician was notified of abnormal blood sugar readings as ordered for 1 of 5 residents reviewed for notification of change. (Resident 65)Findings include:The clinical record for Resident 65 was reviewed on 4/7/26 at 2:00 p.m. The diagnoses included, but were not limited to, type two diabetes mellitus, hypertension, and dementia.A care plan, dated 4/2/25, indicated Resident 65 was at risk for complications and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) with an intervention to obtain blood sugars as ordered and to document and notify the physician of abnormal findings.A physician's order, dated 4/3/25 and discontinued 4/2/26, indicated to obtain an Accu Check (blood sugar reading)… […]

• No harm, potential for more than minimal, isolatedF677Apr 10, 2026

  Based on observation, interview and record review, the facility failed to ensure incontinence care was provided to a resident with urinary incontinence and more than one incontinence brief was not utilized for 1 of 2 residents reviewed for Activities of Daily Living (ADL) care. (Resident 7)Findings include:1. During an observation, on 4/6/26 at 12:10 p.m., Resident 7 was lying in his bed, and the side of his pants was visibly wet with urine. His room had a urine smell.During an observation, on 4/6/26 at 2:13 p.m., Resident 7 was still wet and the wet color on his pants was fading.During an interview, on 4/6/26 at 2:16 p.m., Certified Nurse Aide (CNA) 6 indicated he checked on residents every two (2) hours. […]

• No harm, potential for more than minimal, isolatedF880Apr 10, 2026

  Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident reviewed infection control. (Resident 7)Findings include:The clinical record for Resident 7 was reviewed on 4/8/26 at 10:12 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia without lower urinary tract symptoms, vascular dementia, and intellectual disability.A physician's order, dated 3/8/26, indicated to utilize Enhanced Barrier Precautions when engaging in high contact resident care activities every shift related to a gastrostomy tube.A current care plan, dated 3/9/26, indicated Resident 7 required enhanced barrier precautions.During an observation, on 4/8/26 at 1:50 p.m., CNA 4 provided incontinence care to… […]