Sheridan Village NRSG & RHB

In the surveyor’s words

From the most serious findings on record at Sheridan Village NRSG & RHB, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 28, 2024

  Based on observation, interview and record review the facility failed to provide adequate supervision to prevent a fall during incontinence care for one (R1) of three residents (R1, R3 and R4) reviewed for falls. This failure resulted in a fall by R1 who sustained a laceration on the forehead and was sent to the hospital emergency room receiving stitches to repair the laceration. Findings include: R1 is a [AGE] year old male resident with a diagnosis including COPD, Paranoid schizophrenia, Heart failure, Diabetes 2, Anxiety disorder, Depressive disorder severe with psychotic features and Obesity. R1 has a BIMS (Brief Interview for Mental Status) score of 12/15. […]

• Actual harm, isolatedF689Apr 11, 2024

  Based on observation, interview and record review, the facility failed to adequately supervise one resident (R3). This failure affected 1 resident (R3) causing R3 to sustain a right eyebrow laceration with one suture to R3's face. Findings include: R3's Brief Interview for Mental Status (BIMS) dated 03/07/24 show that R3 has no BIMS score and indicates that R3 has memory problems. The facility's initial Reportable Incident to the local state agency dated 03/21/24 at 7:18 pm documents, in part that CNA (Certified Nursing Assistant) reported to the nurse on duty that R3 was observed in a sitting position on R3's bedside floor mat. Upon nurse head to toe assessment and observation, R3 was noted with a 1/2-by-1/2 laceration and minimal amount of blood to the right side of R3's brow. […]

• Actual harm, isolatedF686Jun 23, 2023

  Based on observations, interviews, and record reviews the facility failed to follow their wound prevention policy to ensure 2 [R7, R10] residents did not develop pressure wounds and the facility failed to prevent pressure wounds from worsening for 1 [R7] resident. These failures resulted in R7 and R10 developing facility acquired pressure wounds; [R7] stage-4 (sacrum), stage-3 (left lateral heel), stage-2 (left fifth toe), and [R10] stage-3 (right ankle). Findings include, R7's clinical record documents in part; medical diagnosis of hypertensive heart disease without heart failure, weakness, need for assistance with personal care, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and bipolar disorder. […]

• Actual harm, isolatedF686Dec 2, 2021

  Based on observation, interview and record review, the facility failed to perform the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures caused R3's sacral pressure ulcer wound to decline and increase in size. Findings include: R3's Face Sheet documents, in part, that R3 is a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS), dated [DATE], documents, in part, that R3 has a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R3 is cognitively intact. On 11/29/21 at 12:26 pm, R3 was observed lying in bed with blankets covering R3's body from the waist to the foot of the bed. […]

• Actual harm, isolatedF689Oct 26, 2021

  Based upon interview and record review, the facility failed to provide supervision for one resident (R1) reviewed for supervision in the sample of 7. The facility failure resulted in R1 eloping from the facility, falling 2 times and sustaining multiple fractures and a brain bleed. Findings include: On 10/19/2021 at 1:19pm, surveyor inquired about the incident on 09/14/2021. R1 stated, I (R1) was outside, walking. Then I (R1) fell and broke my (R1) arm. Surveyor asked R1, how she (R1) got out of facility door. R1 stated she (R1) does not know, I (R1) was outside walking. On 10/20/2021 at 12:07pm, V10 (PRSD - Psychiatric Rehabilitation Service Director) stated, R1 has history of mental illness. Schizo affective depressive type. R1 hears voices. […]