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Deficiency Records for Sheridan Health and Rehabilitation Center
A list of the most recent deficiencies for Sheridan Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sheridan Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-08-22 | 2025-01-31 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-11-19 | 2024-12-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-11-19 | 2024-12-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-19 | 2024-12-19 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-11-19 | 2024-12-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-11-19 | 2024-12-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-11-19 | 2024-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-11-19 | 2024-12-19 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-22 | 2024-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-22 | 2024-09-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-08-22 | 2024-09-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-22 | 2024-09-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-22 | 2024-09-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-08-22 | 2024-09-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-08-22 | 2024-09-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-22 | 2024-09-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-08-22 | 2024-09-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-22 | 2024-09-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-22 | 2024-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-22 | 2024-08-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-22 | 2024-08-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-22 | 2024-08-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-22 | 2024-08-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-08-22 | 2024-08-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-22 | 2024-07-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-22 | 2024-07-24 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-06-22 | 2024-06-26 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-12 | 2023-09-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-12 | 2023-08-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-13 | 2023-08-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-13 | 2023-08-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-13 | 2023-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-08-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-13 | 2023-08-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-08-06 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-07-12 | 2023-08-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-12 | 2023-08-06 | N |
| Have an externally vented heating system. | Fire Safety | 2023-07-12 | 2023-08-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-12 | 2023-08-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-12 | 2023-08-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-13 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-04-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-21 | 2023-04-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-03-21 | 2023-04-10 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-03-21 | 2023-04-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-22 | 2023-04-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-22 | 2023-04-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-22 | 2023-04-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-22 | 2023-04-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-22 | 2023-04-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-22 | 2023-04-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-22 | 2023-04-10 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-22 | 2023-04-10 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-02-22 | 2023-04-10 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-02-22 | 2023-04-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-22 | 2023-04-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-22 | 2023-04-10 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-22 | 2023-04-10 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-02-22 | 2023-04-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-02-22 | 2023-04-10 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-02-22 | 2023-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2023-04-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2023-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2023-01-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-22 | 2023-01-04 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-11-22 | 2023-01-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-16 | 2022-04-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-22 | 2022-04-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-03-22 | 2022-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-22 | 2022-04-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-22 | 2022-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-22 | 2022-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-22 | 2022-04-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-22 | 2022-04-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-22 | 2022-04-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-22 | 2022-04-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-22 | 2022-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-22 | 2022-04-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-03-22 | 2022-04-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-22 | 2022-04-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-22 | 2022-04-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-22 | 2022-04-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-22 | 2022-04-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-22 | 2022-04-19 | Y |
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