Sherrill House

In the surveyor’s words

From the most serious findings on record at Sherrill House, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 10, 2026

  Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing a.) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's recommendations and b.) accurately implement a wound intervention of an air mattress for four Residents (#152, #32 , #4, and #5) out of a total sample of 33 residents. 1.For Resident #152, the facility failed to prevent an existing ankle wound that was present on admission to the facility from worsening from a Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed) pressure ulcer to a Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle) pressure ulcer by not… […]

• Actual harm, isolatedF697Apr 10, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice was provided for one Resident (#4) out of a total sample of 33 residents. Specifically, the facility failed to provide interventions for pain management during wound care treatment, resulting in the Resident experiencing pain during the wound care.Findings include: Review of the facility policy titled 'Pain-Clinical Protocol' dated March 2018, indicated the following but not limited to:-The physician and staff will identify individuals who have pain or who are at risk for having pain. […]

• No harm, potential for more than minimal, patternF658Apr 10, 2026

  Based on observations, interviews, record review, and policy review, the facility failed to ensure that services provided met professional standards for 3 Residents (#146, #42, and #134), out of 33 total sampled residents. Specifically,1.) For Resident #146, the facility failed to notify the provider and obtain and implement Bumex (a diuretic medication) for a weight gain as ordered by the physician.2.) For Resident #42, the facility failed to (2a.) implement a functioning air mattress physician's order, (2b.) complete a wound treatment and dressing documentation in the Treatment Administration Record (TAR).3.) For Resident #134, the facility failed to ensure daily weights were obtained according to the physician's orders. […]

• No harm, potential for more than minimal, patternF761Apr 10, 2026

  Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements in two out of four medication carts observed. Specifically,1.) The facility failed to ensure medications with shortened expiry dates were dated once opened, according to manufacturer's guidelines.2.) The facility failed to ensure medications were stored in the original, labeled containers. Findings include:Review of the facility policy titled 'Medication Storage', revised April 2019, indicated:- Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.-… […]

• No harm, potential for more than minimal, patternF550Jan 16, 2025

  Based on observations and interviews, the facility failed to provide a dignified experience for the residents of the facility by 1) failing to provide a dignified dining experience for the residents on the first floor unit, 2) ensuring a staff member was not on the phone while providing care for one Resident (#129) and 3) ensuring staff members were not storing person items in the room of one Resident (#38), out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Quality of Life - Dignity, dated 2001, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. -Residents should be treated with dignity and respect at all times. […]