Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheridan County Hospital Ltcu during CMS and state inspections, most recent first.
The facility failed to provide required RN coverage for 8 consecutive hours a day, 7 days a week. PBJ records showed multiple days without 8-hour RN coverage, and an administrative nurse verified there was no RN in the LTC unit on those dates, although an RN was on call. An administrative staff member said agency timesheets were sometimes not received before PBJ submission, and no RN coverage policy was provided.
A resident was given antipsychotic and antianxiety meds without adequate supporting documentation for the indication. The chart listed anxiety, dementia with psychotic disturbance, restlessness, and agitation, but the MDS showed intact cognition and no delusions or verbal behaviors. The CAA and care plan referenced olanzapine for agitation with dementia, while the physician also ordered clonazepam for an unapproved sedation/intoxication diagnosis. The facility policy required psychotropic indications to be thoroughly documented with an appropriate diagnosis and behavioral symptoms.
Failure to Include Prophylactic Antibiotic Use and UTI History in Care Plans: Two residents had care plans that did not reflect their UTI history or ongoing prophylactic antibiotic therapy. One resident with urinary retention, Parkinson’s disease, and schizophrenia received daily Bactrim for the bladder, but the care plan did not document the antibiotic use or related monitoring needs. Another resident with a history of UTIs received Macrobid, with interim Cipro orders after UA/culture results, but the care plan did not include the UTI history or long-term antibiotic therapy.
Consultant Pharmacist failed to identify and report ongoing prophylactic antibiotic use for two residents during monthly med reviews, despite a policy requiring review of antibiotic utilization and written reporting of irregularities. One resident had urinary retention, Parkinson’s disease, and schizophrenia, no documented UTI since admission, and a physician order for daily Bactrim prophylaxis for the bladder; the other resident had a history of UTIs, frequent urinary incontinence, and repeated Macrobid use with Cipro given when culture results showed resistance. Staff stated prophylactic antibiotics were not being monitored through the antibiotic stewardship program, and the CP did not alert the facility to the long-term antibiotic use.
A resident with Huntington's disease and severely impaired cognition received hospice services, but the care plan did not identify the hospice agency, specify what supplies hospice would provide, or state how often hospice staff would visit and provide care. Staff were unsure of the hospice name and service details, and the facility did not provide a hospice policy when requested.
Failure to Monitor Prophylactic Antibiotic Use: The facility did not monitor extended prophylactic antibiotic therapy for two residents through its antimicrobial stewardship process. One resident with urinary retention, incontinence, and no documented UTI was ordered daily Bactrim for bladder prophylaxis, but the care plan lacked documentation of UTIs or antibiotic use and the CP did not identify the long-term therapy. Another resident with a history of UTIs, incontinence, and dependence for ADLs was ordered Macrobid prophylaxis, later switched to Cipro after a culture showed resistance, then resumed on Macrobid; staff reported the IP and CP were not monitoring the ongoing antibiotic use.
Incomplete PBJ Staffing Submission: The facility failed to submit accurate direct care staffing data through PBJ. CMS PBJ reports showed no LPN/RN coverage on multiple dates, but payroll records showed a licensed nurse was on duty 24/7. Staff stated the issue may have been related to delayed agency timesheets and noted the facility used 12-hour shifts and agency nurses.
A resident with dementia and other medical conditions was injured during a transfer when staff failed to use a gait belt as required by the care plan. The resident was found unresponsive on the toilet, and during the transfer to the bed, a loud popping noise was heard, resulting in a fracture of the left humerus. Staff admitted to not using a gait belt, citing the emergent nature of the situation.
A resident with a history of falls and impaired cognition was injured after the facility left her electric lift chair remote within reach, despite safety evaluations indicating it was unsafe. The resident, who required assistance for mobility, fell and sustained a head laceration. Observations and staff interviews confirmed the lift chair control was often left within reach, contrary to safety assessments.
The facility failed to implement a water management program to prevent Legionella, placing residents at risk. Additionally, a CNA did not change gloves or wash hands during incontinent care for a resident with prostatic hyperplasia, increasing infection risk. The facility lacked a policy on glove changing and handwashing during such care.
A resident with multiple sclerosis, dependent on staff for daily activities, was not treated with dignity during G-tube medication administration. The resident was left exposed to others through an open window while a nurse administered medications, failing to close the blinds and compromising the resident's privacy.
A facility failed to ensure a resident's PRN Xanax prescription for anxiety had a 14-day stop date or documented rationale for extended use. Despite a physician's order to continue the medication for six months, this was not entered into the resident's EMR or MAR, violating facility policy and CMS regulations. This oversight placed the resident at risk for unnecessary psychotropic medication use.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week. The facility had a census of 27 residents, and the sample included 12 residents. Review of the Payroll Based Journal (PBJ) showed that the facility lacked RN eight-hour coverage on 04/19/25, 05/10/25, 05/17/25, and 05/24/25. On 10/21/25 at 4:00 PM, Administrative Nurse D verified that there was no RN in the Long-Term Care Unit on those dates, although an RN was on call. On 10/22/25 at 7:55 AM, Administrative Staff A stated that a report was run after accounts payable received the timesheet and that there had been times when agency staff timesheets were not received before PBJ submission, which was described as the likely issue. A policy for RN coverage was not provided upon request.
Inadequate documentation for psychotropic medication use
Penalty
Summary
The facility failed to ensure a resident was free from antipsychotic medication use without an appropriate indication. The resident’s record documented anxiety disorder, moderate dementia with psychotic disturbance, restlessness, and agitation. The Significant Change MDS showed a BIMS score of 14, indicating intact cognition, and documented no delusions or verbal behaviors, while also noting the resident required moderate to dependent assistance with ADLs and received antianxiety and antipsychotic medications. The Psychotropic CAA stated the resident had recently started olanzapine daily for agitation with dementia and a delusional state. The care plan documented olanzapine 2.5 mg nightly for agitation with dementia and directed staff to monitor, document, and report changes in cognitive function, with family reassurance and contact with the son or granddaughter as needed. Physician orders included clonazepam 0.5 mg daily for a diagnosis of sedative or intoxication and olanzapine 2.5 mg daily for agitation with dementia. On observation, the resident was seated quietly in a wheelchair at a dining table with staff present, closing her eyes at times. The Administrative Nurse stated the diagnosis of sedation for clonazepam was not an approved diagnosis and that olanzapine was a new order; she also stated the resident had agitation with paranoia. The facility policy required psychotropic medication indications to be thoroughly documented with an appropriate supporting diagnosis and behavioral symptoms being treated.
Failure to Include Prophylactic Antibiotic Use and UTI History in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents who were receiving prophylactic antibiotics related to urinary tract infections. One resident had diagnoses including urinary retention, Parkinson’s disease, and paranoid schizophrenia, was dependent on staff for toileting hygiene, and was frequently incontinent of urine. The resident’s MDS documented no UTIs but did record antibiotic use, and the physician ordered daily Bactrim DS prophylactically for the bladder. The care plan did not document the resident’s UTIs or antibiotic therapy, and the EMR did not show a UTI since admission. The consultant pharmacist’s monthly medication reviews from 03/2025 through 10/2025 did not note the long-term antibiotic use or associated risks. During interviews, administrative nursing staff stated they did not monitor prophylactic antibiotics through the antibiotic stewardship program and acknowledged that the use of the antibiotic and symptoms staff should watch for should have been included on the care plan. Staff also stated the pharmacist only verified renal function and dosage, and the resident had not had UTIs or symptoms since admission. The second resident had diagnoses including a personal history of UTIs, diabetes mellitus, chronic pain, CHF, and anxiety disorder. The resident’s MDS documented intact cognition, dependence for multiple ADLs, a toileting program, frequent urinary incontinence, and no UTIs in 30 days, while also noting antibiotic use. The care plan included assistance needs and toileting schedules but did not include the resident’s history of UTIs or long-term antibiotic use. Physician orders showed Macrobid for the history of UTIs, with later orders to hold Macrobid, give Cipro, repeat a UA, and then resume Macrobid after a urine culture showed resistance to Macrobid.
Consultant Pharmacist Failed to Report Ongoing Prophylactic Antibiotic Use
Penalty
Summary
The facility’s Consultant Pharmacist failed to identify and report ongoing prophylactic antibiotic use for two residents during monthly medication regimen reviews, despite the facility policy requiring review of antibiotic utilization, written reporting of irregularities, and action on those reports. The policy defined irregularities to include unnecessary drugs used for excessive duration, without adequate monitoring, or without adequate indications for use. The pharmacist’s monthly reviews from 03/2025 through 10/2025 did not note the long-term antibiotic use or the associated risks for either resident. For one resident, the EMR documented diagnoses including urinary retention, Parkinson’s disease, and paranoid schizophrenia. The resident’s MDS showed impaired cognition on admission, dependence for toileting hygiene, frequent urinary incontinence, and no UTI, yet the resident received an antibiotic. A physician order dated 02/05/25 directed Bactrim DS 800-160 mg daily as prophylaxis for the bladder. The EMR lacked documentation of any UTI since admission, and the care plan did not document UTIs or antibiotic use. Staff interviews reflected that the antibiotic stewardship program was not monitoring prophylactic antibiotics, and the CP only verified renal function and dosage rather than the ongoing prophylactic use. For the other resident, the EMR documented a history of UTIs, diabetes, chronic pain, CHF, and anxiety disorder. The quarterly MDS showed intact cognition, dependence for multiple ADLs, a toileting program, frequent urinary incontinence, and no UTIs in 30 days, while also documenting antibiotic use. The resident had orders for Macrobid for history of UTIs, later changed to Cipro for a positive urine culture resistant to Macrobid, then resumed Macrobid. Staff interviews indicated the prophylactic antibiotic use was not being monitored through the antibiotic stewardship surveillance, and the CP did not alert the facility to the long-term antibiotic use on monthly medication reviews.
Hospice Care Plan Lacked Key Service Details
Penalty
Summary
The facility failed to provide thorough care planning instruction for a resident with Huntington's disease who was receiving hospice services. The resident's Quarterly MDS documented severely impaired cognition, dependence on staff for all activities of daily living, and hospice services. The care plan dated 10/13/25 stated the family had elected hospice services, that the resident's weight would be obtained monthly for hospice monitoring, and included the hospice phone number, but it did not identify the hospice agency by name. The care plan also directed staff to work cooperatively with the hospice team, but it lacked the hospice company's name, what supplies would be provided, and how often hospice staff would assess and provide care. On 10/21/25, the resident was observed awake, alert, and sitting in a specialized wheelchair in the commons area with involuntary movements. A CNA verified the resident received hospice services but did not know the hospice name, thought the nurse came twice weekly, and was unsure whether hospice aides came. An administrative nurse stated the facility used only one hospice and that visits occurred one to two times per week depending on the resident's needs, family questions, or changes, and she confirmed the care plan lacked the hospice name, visit frequency, and supplies. The facility did not provide a hospice policy when requested.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic use protocols to monitor the effectiveness and evaluate the appropriateness of extended prophylactic antibiotic therapy for two residents. The report states that the facility did not monitor long-term antibiotic use through its antimicrobial stewardship program, and the Consultant Pharmacist monthly medication reviews did not identify the ongoing prophylactic antibiotic use or the risks associated with continued administration for either resident. For one resident, the EMR documented diagnoses including urinary retention, Parkinson’s disease, and paranoid schizophrenia. The resident’s MDS showed impaired cognition on admission and later intact cognition, dependence on staff for toileting hygiene, frequent urinary incontinence, and no UTI. The physician ordered Bactrim DS 800-160 mg daily as prophylaxis for the bladder, but the care plan did not document UTIs or antibiotic use, and the EMR lacked documentation of a UTI since admission. Staff interviews reflected that the prophylactic antibiotic was not being monitored under the antibiotic stewardship program, and nursing leadership stated they could not find physician notes supporting the ongoing use. For the other resident, the EMR documented a history of UTIs along with diabetes, chronic pain, CHF, and anxiety disorder. The resident’s MDS showed intact cognition, dependence for most ADLs, a toileting program, frequent urinary incontinence, and no UTIs in 30 days. The physician ordered Macrobid for the history of UTIs, later changed to Cipro when a urine culture showed resistance to Macrobid, and then Macrobid was resumed. Staff interviews indicated the prophylactic antibiotic use was not being monitored by the infection preventionist or tracked through the stewardship surveillance process, and nursing leadership stated the consultant pharmacist had not alerted the facility to the long-term antibiotic use.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) based on payroll and other verifiable and auditable data. For a census of 27 residents, the CMS PBJ report for FY 2025 Q2 showed no licensed nurse coverage on four dates, and the PBJ for FY 2025 Q3 showed no licensed nurse coverage on three additional dates. However, review of the facility’s licensed nurse payroll data for those dates showed a licensed nurse was on duty 24 hours a day, seven days a week. During interview, the Administrative Nurse stated the facility would never be without a licensed nurse and that nurses were scheduled for 12-hour shifts with agency nurses also available. The Administrative Staff member stated the PBJ report was run after accounts payable received the timesheet and that agency staff timesheets were sometimes not received before PBJ submission, which was described as the likely issue. No PBJ policy was provided upon request.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to safely transfer Resident 1, who had a history of dementia, anxiety, major depressive disorder, and lymphedema, resulting in a broken left humerus. Resident 1 required extensive assistance from two staff members for transfers and was dependent on staff for toileting, bathing, and other activities of daily living. On the day of the incident, Resident 1 was found unresponsive on the toilet by CNA M, who called for assistance from LN G. During the transfer from the toilet to the wheelchair and subsequently to the bed, a gait belt was not used, contrary to the resident's care plan. The incident occurred when CNA M and LN G attempted to transfer Resident 1 without using a gait belt, which was required as per the resident's care plan. The staff lifted Resident 1 by her arms, and during the transfer to the bed, a loud popping noise was heard, and a fracture was later confirmed in Resident 1's left humerus. The staff admitted to not using a gait belt during the transfer, citing the emergent nature of the situation as the reason for their actions. The facility's policy on gait belt use was not followed, which contributed to the injury sustained by Resident 1. The staff involved acknowledged their failure to adhere to the care plan, which specified the use of a gait belt for safe transfers. This oversight led to Resident 1 experiencing a fracture, which required medical attention and resulted in pain and discomfort for the resident.
Removal Plan
- Staff education on following residents' plan of care
- Use of gait belt with transfers
- Completed gait belt audits randomly
Failure to Prevent Resident Falls Due to Unsafe Lift Chair Operation
Penalty
Summary
The facility failed to ensure an environment free from accidents by placing a resident's electric lift chair remote within reach, despite a safety evaluation indicating it was unsafe. The resident, who had a history of anxiety, atrial fibrillation, hypertension, Alzheimer's disease, weakness, and repeated falls, was at high risk for falls due to multiple back surgeries and mobility issues. The resident's care plan noted that she could no longer safely operate the lift chair and required staff assistance for its operation. However, the remote control was left within her reach, leading to a fall that resulted in a head laceration requiring sutures. Observations and interviews revealed that the resident had moderately impaired cognition and was dependent on assistance for mobility and toileting. Despite these needs, the facility's staff continued to leave the lift chair control within the resident's reach, which was against the documented safety assessments. The resident was found on the floor with a head injury after attempting to get to the bathroom, and the chair alarm had been activated, indicating an unsupervised attempt to move. Further observations showed that the resident was often left unsupervised with the lift chair control and call light within reach, despite being blind in one eye and having a history of falls. Staff interviews confirmed that the resident required two-person assistance for transfers and that the lift chair control should have been placed out of reach. The facility's failure to adhere to its Fall Prevention Guidelines and the resident's care plan resulted in the resident's fall and injury.
Infection Control Deficiencies in Water Management and Incontinence Care
Penalty
Summary
The facility failed to implement a water management program to prevent the growth of Legionella and other waterborne pathogens, placing 23 residents at risk of infection. Administrative Nurse D was unaware of the facility's measures to prevent Legionella, and the Maintenance Staff U had started the program but did not know how to proceed with Legionella prevention. The facility's Water Management Program Legionella Policy, revised in March 2023, required identifying and managing conditions that support the spread of Legionella, but the facility did not develop a comprehensive plan for detecting and mitigating these pathogens. Additionally, the facility staff failed to follow proper infection control procedures during incontinent care for a resident, identified as R23. R23 had diagnoses of prostatic hyperplasia and was frequently incontinent of urine and bowel, requiring staff assistance with toilet hygiene. During an observation, a CNA did not change gloves or wash hands after providing perineal care to R23, continuing to provide care with the same soiled gloves. This failure to change gloves and wash hands placed the resident at risk for infection. The facility did not provide a policy regarding glove changing and handwashing during incontinence care.
Failure to Ensure Resident Privacy During G-tube Medication Administration
Penalty
Summary
The facility staff failed to treat Resident 17 with dignity during the administration of medications through a gastrostomy tube (G-tube). Resident 17, who has a diagnosis of multiple sclerosis and is dependent on staff for most activities of daily living, was observed in an electric wheelchair facing a window with the blinds wide open. A licensed nurse entered the room, closed the door, but did not close the window blinds, leaving the resident exposed to other residents and family members outside the window. The nurse proceeded to pull up the resident's shirt, revealing her abdomen and G-tube, to administer medications. The resident's electronic medical record indicated intact cognition with a Brief Interview of Mental Status score of 15. The facility's policy on dignity and respect, revised in 2019, requires staff to honor each resident's dignity and individuality. However, the failure to close the blinds during the G-tube medication administration compromised the resident's privacy and dignity. The administrative nurse later confirmed that staff are expected to ensure privacy by closing both the room door and window blinds during such procedures.
Failure to Ensure PRN Xanax Prescription Had a Stop Date
Penalty
Summary
The facility failed to ensure that a resident's PRN Xanax prescription, used for anxiety, had a 14-day stop date or a documented rationale for extended use with a specified stop date. The resident, who had a diagnosis of bipolar disorder and anxiety, was receiving Xanax as needed without a stop date, which is against the facility's policy and CMS regulations. The physician had documented a continuation of the medication for six months, citing that the benefits outweighed the risks, but this order was not properly entered into the resident's electronic medical record or medication administration record. The resident's care plan included monitoring for signs of depression and anxiety, especially following personal losses, but the facility did not adhere to its policy on psychotropic medication use. The policy requires that PRN orders for such medications are limited to 14 days unless a provider specifies a longer duration with documented rationale. The oversight in not entering a stop date placed the resident at risk for adverse medication side effects and unnecessary psychotropic medication use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hoxie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dawson Place | 17 mi | ★★★★★ | 17 | 0 |
| Trego Co-lemke Memorial Hospital Ltcu | 27.3 mi | ★★★★★ | 1 | 1 |
| Andbe Home, Inc | 36.6 mi | ★★★★★ | 23 | 0 |
| Good Samaritan Society - Decatur County | 38 mi | ★★★★★ | 19 | 0 |
| Logan Manor Community Health Services | 38.1 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.