Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Focused Care At Sherman during CMS and state inspections, most recent first.
Surveyors found that several shared rooms lacked proper privacy curtains for one of the bed spaces, including one room with no curtain or ceiling track, another where the curtain was used to cover an uncovered window leaving the bed end exposed, and a third with a track but no curtain installed. Staff including an LVN, CNAs, an RN, and the Activity Director all acknowledged that privacy and dignity are important for residents’ self-esteem and comfort, and CNAs reported that repair and installation needs were to be entered in a maintenance logbook, but the missing or misused curtains remained unaddressed, leaving affected residents without full visual privacy during care.
Two residents with cognitive impairment and ADL self-care deficits were observed in public areas without adequate protection of their privacy and dignity: a female resident was seated in the lobby and later in the dining room without clothing from the waist down, with her brief and leg exposed up to the hip, and a male resident with an indwelling urinary catheter was in the dining room with his urine collection bag hanging from his wheelchair without a privacy cover. Staff interviews confirmed awareness of the importance of dignity and privacy, and facility policy required residents to be treated with respect and dignity.
The facility failed to ensure timely response to resident call lights, as multiple residents who were alert, oriented, and dependent on assistance due to conditions such as muscle weakness, lack of coordination, blindness, stroke history, and wheelchair use reported waiting from 15 minutes to over an hour for staff to respond. Surveyors repeatedly observed active call lights on the panel while staff, including RNs, LVNs, CNAs, and other personnel, remained at the nurse’s station or in the dining room without attempting to answer them, and test activations of call lights by residents remained unanswered for extended periods. Staff interviews confirmed that everyone was expected to answer call lights, yet no one was specifically assigned during meals, and leadership acknowledged there was no policy or procedure governing response to active call lights or assistance with activities of daily living, resulting in prolonged unmet needs for several residents.
A resident with dementia and other psychiatric diagnoses experienced increased confusion and distress, repeatedly expressing fear and discomfort about her male roommate, whom she no longer recognized. Staff failed to recognize these concerns as possible abuse or neglect, did not investigate or intervene, and lacked a care plan or policy addressing resident relationships and consent. The situation persisted without appropriate action until identified as Immediate Jeopardy by surveyors.
Two residents experienced serious incidents due to inadequate supervision and failure to control environmental hazards. One resident with moderate cognitive impairment eloped from the facility in a wheelchair after being let out by a visitor who had access to the door code, while another resident with limited mobility and impaired hand function sustained a second-degree burn after spilling overheated coffee on herself when left unattended in a reclined position.
Surveyors identified multiple deficiencies in food storage, preparation, and service, including unlabeled and improperly sealed food items, lack of facial hair coverings by dietary staff, failure to clean the grease trap as required, improper storage of broken tiles near open food, and failure to record food temperatures before serving. These actions were confirmed through staff interviews and direct observation.
A resident with dementia and other psychiatric diagnoses repeatedly expressed discomfort and lack of safety sharing a room with a male roommate, whom she no longer recognized. Despite her statements and behaviors indicating distress, staff continued to redirect her back to the shared room without reassessing her safety or updating her care plan, and the facility did not address her capacity to consent to the living arrangement.
Several residents' care plans did not address important aspects such as resident relationships and contracture management, despite staff and family awareness and existing therapy orders. Staff interviews revealed confusion about care planning responsibilities, and documentation showed that care plans were not updated to reflect current needs or physician orders, resulting in incomplete guidance for individualized resident care.
Surveyors found that a resident's insulin pen and a vial of TB PPD were not dated when opened, and multiple vials of flu vaccine and TB PPD were stored in an unsecured office refrigerator. Staff interviews confirmed that opened medications should be dated and securely stored, but these procedures were not followed, in violation of facility policy.
Staff failed to follow infection prevention protocols, including hand hygiene and proper glove use, during blood sugar checks and incontinence care for three residents with diabetes and Alzheimer's. An LVN did not sanitize hands or equipment properly and placed a soiled glucometer on a dining table, while a CNA handled clean briefs with soiled gloves and left a resident's room without hand hygiene. These actions were contrary to facility policy and acknowledged by staff during interviews.
A facility failed to maintain an effective pest control program, resulting in gnats being observed in a resident's room, the kitchen, a hallway, and the nurses' station. Staff and department heads confirmed ongoing issues with gnats, particularly in areas where food was present or consumed. Pest control logs and service records showed repeated reports and treatments for gnats, but the problem persisted across multiple areas of the facility.
The facility did not properly coordinate PASARR assessments or make necessary referrals after a resident was diagnosed with a serious mental illness. Despite documentation of a new schizoaffective disorder diagnosis, required follow-up screenings and reviews were not completed, leading to missed opportunities for appropriate mental health services.
A baseline care plan was not completed within 48 hours of admission for a resident with multiple complex medical needs, including COPD, heart failure, and continuous oxygen use. Only the Social Services section was initiated, and staff interviews revealed confusion about responsibility and lack of training regarding the care plan process. Facility policy required an RN to initiate the plan and for it to address immediate needs through an interdisciplinary approach, which was not followed.
A resident with a history of stroke, arthritis, and left-hand contracture did not receive consistent interventions to maintain or improve range of motion. Despite orders for a hand brace and documentation of the contracture, the care plan lacked appropriate interventions, and the brace order was discontinued without proper interdisciplinary communication. Staff were unclear about the resident's need for a splint, and the required restorative program was not implemented after therapy discharge.
Nursing staff failed to prime insulin pens before administering insulin to two residents with diabetes, contrary to manufacturer instructions and facility policy. One nurse was unaware of the priming requirement, while another forgot to perform the step, resulting in both residents potentially not receiving the full prescribed insulin dose.
A resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors was able to leave the facility unsupervised during a busy event. Staff failed to complete an elopement risk assessment upon admission and did not consistently recognize or communicate the resident's exit-seeking behaviors, resulting in the resident being found several blocks away by a bystander before being returned to the facility.
The facility did not follow its abuse prevention and reporting policy when a resident was witnessed hitting another resident. The incident was not documented in the facility's incident reports, and staff, including the DON and Administrator, were unaware of the event. Although staff are trained on reporting protocols, the required notification to the abuse coordinator and state agency was not made.
The facility failed to secure controlled medications in two medication carts, with broken seals found on bubble packaging cards of Tramadol, Alprazolam, and Lorazepam. Despite appropriate narcotic log counts, the compromised seals posed a risk of drug diversion. Staff interviews revealed that the broken seals were not noticed during routine counts, and the facility's policy for handling such issues was not followed.
A resident with severe cognitive impairment and chronic pain did not receive their scheduled Fentanyl patch due to misappropriation by an RN, who used the patch for personal recreational use. The RN, with a history of substance abuse, was found unresponsive due to an overdose, leading to emergency intervention. The facility's policy against medication diversion was violated.
A resident with severe cognitive impairment and frequent incontinence developed a pressure ulcer on the lower back, which was not treated in a timely manner due to communication and documentation failures. Despite weekly skin assessments indicating the presence of a wound, the WCN was not informed until several days later, delaying treatment. The facility's protocols for wound care and skin management were not effectively followed, leading to a deficiency in care.
Failure to Provide Privacy Curtains for Multiple Bed Spaces
Penalty
Summary
The deficiency involves the facility’s failure to ensure full visual privacy for residents in three of twelve rooms reviewed, specifically the B beds in rooms identified in the report. Surveyor observations showed that one room lacked a privacy curtain for Bed B and did not even have a ceiling track installed to allow a curtain to be hung. In another room, the privacy curtain for Bed B had been repositioned over the window because the window did not have its own curtain, leaving the end of Bed B exposed. A third room had a ceiling track installed for a privacy curtain for Bed B, but no curtain was present. The report states that this failure placed residents at risk for no visual privacy during care, which could cause decreased feelings of self-worth. Multiple staff interviews confirmed that privacy and dignity were recognized as important aspects of resident care. The Activity Director, LVN, CNAs, and RN all stated that residents had a right to privacy, that the facility was the residents’ home, and that protecting privacy was important for dignity, self-esteem, comfort, and helping residents feel safe and valued. CNAs reported that requests for repairs, including hanging curtains, were placed in a maintenance logbook, and one CNA stated she had not noticed the lack of curtains on the 100 Hall and that maintenance was responsible for hanging curtains. An attempted interview with the Director of Plant Operations was unsuccessful. Review of the facility’s “Quality of Life – Homelike Environment” policy from May 2017 reflected that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Protect Resident Dignity and Privacy in Public Areas
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity by allowing two residents to remain exposed in public areas. One resident, an elderly female with dementia, severe cognitive impairment (BIMS score of 7), wheelchair use, and total dependence on staff for ADLs including lower body dressing, was observed in the main lobby in a reclining chair with a blanket moved to the side and no clothing from the waist down, leaving her brief exposed. When asked if she wanted to cover up or wear pants, she declined. Later the same day, she was observed in the dining room eating her noon meal in the same reclining chair with her left leg exposed up to her hip and her brief visible, while other residents were in the immediate area. Her care plan documented an ADL self-care deficit and bowel and bladder incontinence. A second resident, an elderly male with kidney failure, complications of an indwelling urinary catheter, Parkinson’s disease, moderate cognitive impairment (BIMS score of 9), and dependence on staff for most ADLs, was observed eating his noon meal in the main dining room with his urine collection bag hanging from his wheelchair without a privacy cover. His care plan documented bladder incontinence, an indwelling catheter, and an ADL self-care deficit. Multiple staff interviews, including with the Activity Director, LVN, CNAs, RN, and ADON, confirmed their understanding that residents’ privacy, dignity, and self-esteem should be protected, that residents should not be exposed to others, and that the facility is the residents’ home. The ADON stated she was not aware that the male resident had been out without a privacy cover on his urine collection bag or that the female resident had exposed herself by pulling off her blanket, and stated the female resident should have been fully dressed. The facility’s Resident Rights policy required employees to treat all residents with kindness, respect, and dignity and affirmed residents’ rights to a dignified existence and to be treated with respect, kindness, and dignity.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident call lights were answered within a reasonable time, affecting three residents who relied on the call system for assistance. During initial rounds, surveyors observed two active call lights on the panel at the nurse’s station while three staff members sat at the station typing on computers without attempting to respond. One resident, who used a wheelchair and had diagnoses including muscle weakness, unsteadiness, lack of coordination, hyperlipidemia, and erosive osteoarthritis, reported that call light response times usually ranged from 15–30 minutes and sometimes up to an hour. At his request, his call light was activated and remained unanswered for approximately 23 minutes while staff, including an RN and the Facility Administrator, were present and made no attempt to respond. A floor technician reported that while working in laundry and housekeeping, he frequently observed residents waiting 30 minutes to an hour or longer for call lights to be answered, and that residents sometimes asked him to get a nurse because their call lights had been on for an hour without response. On the same day, staffing records showed four CNAs on duty for the morning shift, all of whom were observed in the dining room passing trays at noon, with no staff member observed as assigned to answer call lights during the meal. Multiple staff, including an RN, a CMA, and a CNA, stated that everyone could answer call lights and that there was no reason for licensed nurses not to respond, and one CMA stated her expectation that call lights should be answered within ten minutes. However, surveyors repeatedly observed active call lights on the panel with no attempts by available staff, including RNs and LVNs, to answer them. Two additional residents, both alert and oriented with BIMS scores of 15, reported prolonged call light response times. One resident, with a history of stroke, unsteadiness, lack of coordination, and wheelchair use, stated that call lights were answered anywhere from 15 minutes to one and one-half hours and activated his call light during the interview; another resident, who was blind with multiple diagnoses including repeated falls, myocardial infarction, anxiety disorder, muscle weakness, lack of coordination, cancer, hypertension, and polyneuropathy, stated that it took too long for call lights to be answered and that her family member sometimes had to help her lift her legs into bed. Both residents’ call lights remained unanswered at the end of a 45-minute interview. Later observations again showed two room call lights active while an RN, an LVN, and a CNA sat at the nurse’s station typing on computers without responding. In an interview with leadership staff, it was confirmed that the facility had no policy or procedure for any staff member regarding answering active call lights and assisting residents with needs and activities of daily living.
Failure to Prevent and Address Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for a resident with moderate to severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia, experienced increased confusion and no longer recognized her male roommate, with whom she previously had a relationship. Despite repeated expressions of fear and discomfort about her roommate, staff did not recognize these as possible allegations of abuse or neglect, nor did they investigate or intervene appropriately. The resident was observed repeatedly asking to leave, expressing fear of the roommate, and refusing to be in the same room or sit with him, yet staff continued to redirect her without addressing her underlying concerns or reassessing the appropriateness of the cohabitation arrangement. Progress notes and staff interviews revealed that the resident's confusion and distress persisted over several days, with staff documenting her statements about a 'creepy man' in her room and her refusal to be left alone with him. Despite these clear indications of psychosocial harm and potential neglect, there was no care plan addressing the cohabitation or relationship, and no assessment of the resident's capacity to consent to the relationship. Staff, including LVNs, the ADON, and the DON, failed to recognize the situation as a possible allegation of abuse or neglect, and did not report or protect the resident from further psychosocial harm. The facility also lacked a policy regarding resident capacity or consent for relationships and did not have procedures in place to assess or document consent when a resident's cognitive status changed. Interviews with staff and leadership confirmed that concerns about the resident's safety and consent were not escalated or addressed in a timely manner. The DON and Executive Director were unaware of the specific language used in progress notes indicating fear and discomfort, and there was no investigation or intervention until the situation was identified as Immediate Jeopardy by surveyors. The facility's failure to identify, report, and intervene placed the resident at risk for continued psychosocial harm and did not ensure her right to be free from abuse, neglect, and exploitation.
Failure to Prevent Elopement and Hot Liquid Burn Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was moderately cognitively impaired and assessed at medium risk for elopement, was able to leave the facility in his wheelchair without staff knowledge. The resident was found outside the facility at a nearby intersection, having been let out by a family member of another resident who had access to the door code. The door alarm did not sound, and staff were unaware of the resident's absence until he was returned by a nurse who happened to see him outside. The resident had no prior history of exit-seeking behavior, and the care plan required supervision while smoking but did not anticipate this type of elopement. Another resident, also moderately cognitively impaired and with limited mobility, sustained a second-degree burn after spilling hot coffee on herself. The resident had requested her coffee be reheated, and a CNA used the microwave to heat the beverage before returning it to the resident, who was lying with her bed head lowered. The CNA placed the coffee on the overbed table and left the room after warning the resident that it was hot. The resident attempted to drink the coffee without raising her head, resulting in the spill and subsequent burn to her chin and chest. The resident had difficulty grasping the cup due to weakness in her left hand and was right-handed but wore a wrist splint on her right wrist. In both cases, the facility did not implement or enforce adequate supervision or safety measures to prevent the incidents. The first resident was able to exit the building due to a lack of control over access codes and insufficient monitoring of visitors' actions. The second resident was given a hot beverage without proper assessment of her ability to safely consume it in her current position, and the staff member did not ensure the resident was sitting up before leaving the coffee within reach.
Food Storage, Preparation, and Service Deficiencies Identified
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in its only kitchen. Observations revealed multiple food items in the facility's refrigerators and freezers that were not labeled or dated, including opened bags of bacon, lettuce, onions, tomatoes, and other items. Some food items were not properly sealed, and containers of liquids such as tea and water were found without covers or labels. Additionally, opened and unsealed bags of vegetables and other foods were stored inappropriately, and broken kitchen tiles were stored on shelves near open food items. Dietary staff were observed preparing and serving food without wearing required facial hair coverings. The staff acknowledged the availability of facial hair coverings but did not use them, stating that the coverings were ineffective and that they were awaiting new ones. The grease trap on the cooking griddle was found to be dirty, with a significant buildup of grime and liquid, and was not emptied or cleaned after each use as required. The staff admitted to emptying the trap only once daily, contrary to expectations, and could not recall when it was last cleaned. Meal temperature logs showed that food temperatures were not taken or recorded for certain meals, and staff admitted to forgetting to check temperatures before serving food. During meal service, food was served without verifying that it had reached safe temperatures. Facility policies required all food to be labeled, sealed, and stored properly, and for staff to wear appropriate uniforms, including facial hair coverings, while preparing and serving food. These deficiencies were confirmed through interviews with dietary staff and the Director of Food Services, who acknowledged the lapses in following established procedures.
Failure to Protect Resident from Emotional Distress Due to Unaddressed Roommate Concerns
Penalty
Summary
The facility failed to protect a female resident's right to be free from abuse and neglect when she expressed discomfort and a lack of safety sharing a room with a male resident. Despite the resident's repeated statements that she did not know her roommate, did not want to be in the same room with him, and described him as 'creepy' and 'weird,' the facility did not address her concerns or take action to separate them. The resident, who had a history of dementia, anxiety, depression, bipolar disorder, schizophrenia, and a BIMS score indicating moderate to severe cognitive impairment, exhibited increased confusion, exit-seeking behaviors, and distress related to her roommate. Progress notes documented her confusion, refusal to return to her room, and requests for help to leave the situation, yet staff continued to redirect her back to the same environment without reassessing her safety or consent to the living arrangement. The care plans for both residents did not address their cohabitation or relationship, and there was no assessment of the female resident's capacity to consent to the relationship after her cognitive decline. Staff interviews revealed that although the residents had previously been considered companions, the female resident's cognitive status had changed significantly, leading her to no longer recognize her roommate or recall their relationship. Multiple staff members noted her discomfort and confusion, but the facility did not implement interventions to ensure her safety or dignity, nor did they update her care plan to reflect her wishes or current condition. Facility policy required immediate protection of residents suspected of being abused or neglected, including assessment and intervention to prevent further harm. However, the facility did not follow these procedures when the resident's statements and behaviors indicated distress and a lack of consent to her living situation. The deficiency was identified through observation, interviews, and record review, and it was determined that the facility's failure to act placed the resident at risk for emotional harm and mental anguish.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically neglecting to address resident relationships and a contracture management need. For multiple residents who were in consensual, non-sexual relationships or cohabitating, the care plans did not include any mention of these relationships, despite staff and family awareness. Interviews with staff, including the DON, ADON, and Executive Director, revealed uncertainty or lack of clarity about whether such relationships should be care planned, even though the Regional MDS Coordinator and other staff acknowledged the importance of including these aspects to ensure resident rights, privacy, and safety. In the case of a resident with a left-hand contracture, the care plan did not reflect the need for or use of a splint or brace, despite therapy orders and documentation in the facility's contracture management logs. Observations showed the resident without the prescribed splint, and interviews with staff indicated a lack of awareness or follow-through regarding the order and its inclusion in the care plan. The Director of Rehabilitation confirmed that the splint was necessary and should have been care planned, but noted that the order had been discontinued without his knowledge and that the care plan was not updated accordingly. Record reviews and staff interviews consistently demonstrated that care plans were not updated to reflect all current physician orders, therapy recommendations, and resident needs, particularly in the areas of psychosocial relationships and contracture management. The facility's own policy required the interdisciplinary team to review practitioner notes and orders and implement a comprehensive care plan, but this was not done for the residents in question. As a result, staff may not have been fully informed of or able to address the individualized needs of these residents.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. An insulin pen used for a resident was not dated when opened, and the nurse administering the medication was unable to determine how long the pen had been in use. The nurse acknowledged that insulin pens are required to be dated upon opening and that failure to do so could result in the use of expired medication. The Director of Nursing confirmed that the pen should have been dated and that not doing so could lead to ineffective treatment. Additionally, an open vial of Tuberculin Purified Protein Derivative (TB PPD) was found in a refrigerator located in an unlocked office, along with several unopened vials of flu vaccine and TB PPD. The treatment nurse stated that opened vials must be dated and that the current storage location was not secure, as the office was accessible during the day. The Director of Nursing was unaware that these medications were stored outside the medication room and confirmed that they should be kept in a secured medication room refrigerator. Facility policies reviewed by surveyors required dating of opened medications and secure storage, which was not followed in these instances.
Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing required hand hygiene during resident care. In one case, a male resident with type 2 diabetes had his blood sugar checked by an LVN who did not perform hand hygiene before or after the procedure, nor after cleaning the glucometer. The LVN changed gloves multiple times without sanitizing her hands and handled the glucometer and medication cart without proper infection control practices. Another incident involved a male resident with type 2 diabetes whose blood sugar was checked by the same LVN in the dining room. The LVN did not perform hand hygiene before or after the procedure, placed the soiled glucometer on the dining room table, and changed gloves without sanitizing her hands. The LVN acknowledged she was aware of the required protocols but did not have hand sanitizer on her cart and admitted to the risk of cross-contamination by her actions. The resident stated he would have complied with being moved for the procedure if asked. A third incident involved a female resident with Alzheimer's who received peri-care from a CNA who did not perform hand hygiene before or after care, and handled clean briefs with soiled gloves. The CNA also left the resident's room without sanitizing her hands. The CNA stated she believed wearing gloves kept her hands clean and was unaware of the need to change gloves and perform hand hygiene between glove changes. The facility's policy required hand hygiene before and after care, after glove removal, and after contact with potentially contaminated surfaces.
Failure to Maintain Effective Pest Control Program Resulting in Gnat Infestation
Penalty
Summary
The facility failed to implement and maintain an effective pest control program, resulting in the presence of gnats in multiple areas, including a resident's room, the kitchen, a hallway, and the nurses' station. Observations revealed that a resident was found in bed with food crumbs on the linens and floor, and several gnats flying around and landing on her bed and bedside table. The resident reported that the gnats had been present for some time and were bothersome, though she had become accustomed to them. Housekeeping staff confirmed that the room was cleaned regularly and that gnats were noted, particularly due to food being consumed in the room. The Director of Environmental Services acknowledged that food spills and delayed meal tray pickups contributed to the gnat problem in the resident's room. In the kitchen, multiple observations during meal service documented gnats flying around and landing on bread rolls. The Director of Food Services was aware of the issue and attributed it to gnats coming from the drains, noting that bleach was used in the drains and monthly fumigation was performed. Despite these efforts, gnats continued to be observed in the kitchen, posing a risk of food contamination. Additional observations found gnats in a hallway and at the nurses' station, with staff interviews confirming that gnats had been seen in these areas and that sightings were recorded in the pest control log. Review of pest control service agreements and logs showed that pest control services were performed monthly, with additional treatments as needed when issues were reported. However, pest logs indicated repeated reports of gnats in various locations over several months. Invoices from the pest control company documented treatments for gnats, but also noted occasions when gnats were not addressed. The facility's pest control policy was requested but not provided during the survey.
Failure to Coordinate PASARR Assessments and Referrals for Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program, resulting in missed referrals and duplicative efforts for residents with mental health diagnoses. Specifically, for one resident, the facility did not refer for a Level II PASARR screening or complete a Mental Illness Resident Review after a new diagnosis of schizoaffective disorder was added by the primary care provider. The initial PASARR Level I screening did not indicate mental illness, but subsequent documentation showed the onset of a serious mental illness, which was not followed by the required referral or updated assessment. Interview with the Regional MDS Coordinator confirmed that the process for monitoring new diagnoses and making appropriate referrals was not followed, as the order for the new mental health diagnosis was uploaded but not communicated effectively. The facility's policy required timely and accurate completion of PASARRs and coordination with state authorities for any changes in resident status, but this was not adhered to in this case, resulting in the resident not being properly assessed for needed mental health services.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by policy. Specifically, the baseline care plan for a moderately cognitively impaired female resident with chronic obstructive pulmonary disease, heart failure, and continuous oxygen needs was not completed. Only the Social Services section of the care plan was initiated, and no further interdisciplinary input was documented. Interviews with nursing staff, including RNs and LVNs, revealed a lack of clarity and training regarding responsibility for completing the baseline care plan. Several staff members assumed that either the DON or the MDS nurse was responsible, while the DON stated that the admitting nurse should initiate the plan and that it did not have to be an RN. The Corporate MDS Nurse confirmed that the baseline care plan was missing and described the intended interdisciplinary process, which was not followed in this case. Review of facility policies indicated that a baseline care plan must be completed within 48 hours of admission, initiated by an RN, and should address immediate needs based on admission orders, including physician, dietary, therapy, and social services input. The lack of a completed baseline care plan for the resident meant that her immediate needs, such as oxygen therapy, Foley catheter care, and infection management, were not formally addressed in a person-centered, interdisciplinary manner as required.
Failure to Provide Consistent Contracture Management for Resident with Limited ROM
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, arthritis, non-Alzheimer's dementia, and left-hand contracture did not receive appropriate interventions to maintain or improve range of motion. The resident was dependent on staff for most activities of daily living and had documented orders for a left-hand brace to prevent further contracture. However, the care plan did not include interventions for the contracture or the use of a brace, and the brace order was discontinued without proper interdisciplinary communication or documentation of medical necessity. Observations revealed the resident was not wearing a splint or brace, and staff interviews indicated confusion regarding the status of the order and the location of the brace. Some staff were unaware of the resident's need for a splint, while others reported the resident had previously used one but was not currently wearing it. The Director of Rehabilitation confirmed the resident required a splint and that the order had been discontinued without his input. The ADON stated the order was discontinued at the request of the resident's family due to poor fit, but could not recall if therapy was consulted before discontinuation. Record reviews showed the resident was listed on the facility's contracture management logs as needing a splint, but the occupational therapy discharge summary did not mention the contracture or splint. The facility's policy required therapy to develop and implement a restorative program upon discharge from therapy, but there was no evidence this was done for the resident. As a result, the resident did not receive consistent or appropriate interventions to address her contracture, as required by her condition and physician orders.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
The facility failed to ensure that nursing staff followed manufacturer instructions for priming insulin pens prior to administering insulin to two residents with Type 2 diabetes. In the first instance, a nurse performed a fingerstick blood sugar test for a female resident, determined the required insulin dose per sliding scale, and administered the insulin using an Insulin Aspart pen without priming it. The nurse later stated she was unaware of the need to prime the pen before each dose and had not been instructed on this step during her training. In the second instance, another nurse administered Lyumjev insulin to a male resident after receiving a physician's order for a specific dose, again without priming the insulin pen. This nurse acknowledged awareness of the priming requirement but stated she forgot to perform the step. The Director of Nursing confirmed that insulin pens are to be primed before each injection and that failure to do so could result in residents not receiving the prescribed amount of insulin. Facility policy and manufacturer instructions both require priming of insulin pens before each use.
Failure to Prevent Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision or implement necessary interventions to prevent an elopement incident involving a resident with significant cognitive impairment. The resident, who had diagnoses including dementia, Alzheimer's disease, and a history of wandering and exit-seeking behaviors, was admitted from another skilled nursing facility with documentation indicating a need for redirection and a secure unit placement if necessary. Despite this, an elopement risk assessment was not completed upon admission, and staff were not consistently aware of or acting upon the resident's exit-seeking behaviors, which were documented in progress notes and observed by staff. On the day of the incident, the resident was last seen at a facility event with many visitors present. The resident was able to leave the facility unnoticed, and staff were unaware of the elopement until notified by an external party. The resident was found several blocks away in a residential area by a bystander, who contacted the resident's responsible party using the resident's cell phone. The responsible party then returned the resident to the facility. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, incomplete communication about the resident's behaviors, and failure to follow facility policy requiring elopement risk assessment upon admission and when exit-seeking behaviors are observed. Documentation and interviews confirmed that the baseline care plan identified the resident as an elopement risk, but this information was not effectively communicated or acted upon by the admitting nurse or other staff. The responsible party was not involved in care planning discussions regarding the resident's risk or the need for secure unit placement prior to the incident. The facility's failure to assess, monitor, and implement appropriate interventions for a resident with known risk factors for elopement resulted in the resident leaving the facility unsupervised and unrecognized by staff.
Failure to Report Resident-to-Resident Altercation per Abuse Policy
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse for two residents, as evidenced by an unreported resident-to-resident altercation. According to the facility's abuse policy, any event involving an allegation of abuse or suspicious injury must be reported immediately or within two hours. However, a review of incident reports over a three-month period did not reveal any documentation of an altercation that occurred between two residents, despite nurse's notes indicating that one resident was witnessed hitting another. The nurse intervened and educated the resident but did not assess the resident or report the incident as required by policy. Interviews with staff, including the RN, CNA, DON, and Administrator, revealed that none were aware of the incident, and all confirmed knowledge of the facility's abuse reporting protocols. The DON and Administrator both stated that the incident should have been reported according to policy and that staff are trained on these procedures. The failure to report the incident as outlined in the facility's policy represents a deficiency in the implementation of abuse prevention and reporting protocols.
Failure to Secure Controlled Medications in Medication Carts
Penalty
Summary
The facility failed to ensure the security and proper storage of controlled medications in two medication carts, leading to potential risks for residents. During an observation of Medication Cart #1, it was found that a pill bubble packaging card containing Tramadol 50 mg tablets had seals that were not intact and were covered with tape. Additionally, a full pill bubble packaging card of Alprazolam 0.25 mg had one seal that was not intact. Despite the narcotic log count sheet reflecting the appropriate count, the compromised seals indicated a failure in maintaining the security of these controlled substances. Similarly, Medication Cart #2 was found to have a pill bubble packaging card of Lorazepam 0.5 mg with one seal not intact. The narcotic log count sheet again reflected the appropriate count, but the broken seal posed a risk of drug diversion. Interviews with staff revealed that controlled medications were counted at the beginning and end of shifts, but the broken seals were not noticed during these counts. The Director of Nursing (DON) confirmed that nurses were responsible for following medication rights and should notify the DON and discard any compromised pills with a second nurse. The facility's policy required that drug containers with missing or incorrect labels be returned to the pharmacy, but this protocol was not followed in these instances.
Misappropriation of Resident's Fentanyl Patch by RN
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their prescribed medication, specifically a Fentanyl patch, by a registered nurse (RN A). The resident, an elderly female with severe cognitive impairment and chronic pain conditions, was under a scheduled pain medication regimen that included the application of a Fentanyl transdermal patch every 72 hours. On the day of the incident, RN A attempted to replace the resident's Fentanyl patch but reported that the resident refused the procedure. Despite this, RN A had already signed off on the narcotic sheet indicating the patch had been administered. RN A subsequently misappropriated the Fentanyl patch for personal use, shredding the narcotic count sheet to conceal the missing patch. Later that day, RN A was found unresponsive in the staff bathroom, exhibiting signs of opioid overdose. A Fentanyl patch was discovered on the bathroom floor, and it was revealed that RN A had a history of substance abuse and had relapsed, using the resident's medication for recreational purposes. This incident resulted in the resident not receiving their scheduled pain management, potentially affecting their quality of life. The facility's Director of Nursing (DON) and other staff members discovered RN A in a compromised state, leading to emergency medical intervention. The DON initiated an investigation and suspended RN A, who was later terminated. The facility's policy on abuse, neglect, and exploitation explicitly prohibits the misappropriation of resident property, including medication diversion for staff use, which was violated in this case.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, a female with severe cognitive impairment and frequent incontinence, had a history of pressure ulcers and skin integrity issues. Despite documentation of a pressure ulcer on the resident's lower back in weekly skin assessments, the wound care nurse (WCN) was not notified until several days later, resulting in a lack of treatment for the wound until it was assessed on June 6th. The resident's care plan included interventions for monitoring and treating skin injuries, but these were not consistently followed. Weekly skin assessments were documented by LVN A, but they lacked specific details about the wound's location and type. The WCN was unaware of the wound until informed by a resident care provider (RCP) on June 6th, who discovered the open area during routine care. The WCN then assessed the wound, notified the primary care physician, and initiated treatment. However, the wound care was not documented as performed on June 12th, and there were discrepancies in the records regarding the completion of weekly skin assessments. Interviews with staff revealed a breakdown in communication and documentation processes. The WCN relied on nurses to report any skin breakdowns observed during assessments, while the RCPs were expected to report skin issues to the charge nurse. LVN A claimed to have informed the WCN about the wound, but this was not documented. The facility's protocols for wound care and skin management were not effectively implemented, leading to the deficiency in providing timely and appropriate care for the resident's pressure ulcer.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 113 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sherman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Texoma Healthcare Center | 2.9 mi | ★★★★★ | 16 | 0 |
| Cedar Hollow Rehabilitation Center | 3.1 mi | ★★★★★ | 7 | 2 |
| Avir At Sherman | 3.5 mi | ★★★★★ | 5 | 0 |
| Beacon Hill | 7.1 mi | ★★★★★ | 10 | 0 |
| Denison Nursing And Rehab | 9 mi | ★★★★★ | 3 | 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.