Inspection visit

Health inspectionSeptember 13, 2022

SHERIDAN MEDICAL LODGECMS #6764158 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups for Resident Council Meetings reviewed for grievances consisting of six residents who regularly attend the meetings and complain about residents who smoke and congregate in front of their rooms. Residents Affected - Some The facility failed to comply with grievances voiced by residents 6 in the resident council meeting held on August 29, 2022, and April 25, 2022, consisting of these residents and 26 other residents were in attendance on April 29, 2022. The Administrator and Activity Director were invited to attend. Six residents of 20 residents attend on August 29, 2022, regarding the complaints regarding smokers who obstruct Resident #14, #44, #48, #78, and #108 rooms. These failures could place residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: Review of Resident Council Meeting Minutes and Grievances reveal the following: April 29, 2022 Smoking near the door in the evenings and the rooms get to smelling bad. Can the residents enter and exit through the dining room door to keep smoke from coming into the 300 hall and those residents' rooms? August 29, 2022. The smoker's line up hour early sometimes before the smoking time and talk very loudly and the three rooms (302,303,304) room and the door are often blocked, and they are very disruptive to the residents who live on the 300 halls. During a Confidential Group Resident Interview on 9/12/22 at 2:30 PM stated smokers who go to the exit on the 300 hall makes it hard to get to their rooms who live across from the exit door because all the smokers are in wheelchairs. The resident smokers waiting to smoke at the smoking area are obstructing the pathways in and out of their rooms.They said even visitors who come and visit them makes it hard to get to their rooms. They said the smoke smell is irritating and probably where the flies come from inside the building. The congregating also creates a very noisy atmosphere and makes it hard to take naps. During an interview with Administrator on 09/13/2022 at 8:50 AM, he said he was aware of the issues residents on the 300 hall was having with the smokers and the smokers have the right to sit there if they want to. He said the recommendation by the resident council was to go through the dining room where they (smokers) are not obstructing the pathway to resident rooms who live near the smoking (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 16 Event ID: 676415 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some area. He said the residents would then be obstructing the dining room area. The Administrator said the solution would be to have a non-smoking facility but cannot do that at this time because he did not infringe on the rights of the current smokers. He said he did not think the collection of smokers in wheelchairs would prevent the egress in case of a fire. He said he was aware of the complaints and said residents who smoke have a right to sit where they want to and if they should stay on one side of the hall. But aware this a continuing problem. During an interview with the Activity Director on 09/13/2022 at 10:00 AM she said she made the Administration (Administrator) aware of the complaint's resident had regarding the smokers and wanting the Administrator make the changes necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 1 of 3 residents (Resident #89) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. Residents Affected - Few 1. The facility failed to ensure Resident #89 was given a SNF ABN (Form CMS-10055) in addition to the NOMNC (Form CMS-10123 general notice) when he was discharged from skilled services. 2. The facility failed to ensure Resident #89 was given a NOMNC (Notice of Medicare Non-Coverage) in addition to the SNF ABN when he was discharged from skilled services. These failures could place residents at risk of not being fully informed about services covered by Medicare. The findings include: Review of Resident #89's admission Record/Face Sheet, dated 9/13/22, revealed an [AGE] year-old male who was initially admitted to the facility on [DATE] with a primary diagnosis of pneumonia. Additional diagnoses included cerebral infarction, unspecified; chronic kidney disease, unspecified; ischemic cardiomyopathy; paroxysmal atrial fibrillation; weakness, and history of falling. The record reflected the resident had Medicaid coverage Part B and Medicaid pending. Review of Resident #89's progress note, dated 08/23/22, revealed the MDS Coordinator documented she had contacted Resident #89's daughter (responsible party) with NOMNC information. The note reflected the family member verbalized understanding of skilled care, the need for discharge when goals were met or maximum function was met, and of the appeal process; she did not wish to appeal at this time. Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #89 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The form reflected a SNF ABN, Form CMS-10055, was provided and acknowledged by the beneficiary or the beneficiary representative. The form reflected a NOMNC, Form CMS-10123) was provided and acknowledged by the beneficiary or the beneficiary's representative. Review of the NOMNC form (Form CMS-10123) revealed notification was made to Resident #89's family member via telephone on 08/23/22. The form was not mailed or signed by the resident. A SNF ABN form (Form CMS-10055) was completed but was not signed by the resident or resident's representative. In an interview on 09/13/22at 1:42 PM, the MDS Coordinator said Resident #89 was reluctant and refused to sign the NOMNC and the SNF ABN forms. She contacted the resident's daughter and informed her. The daughter said she would come up the facility and sign it, but she never showed up. She has not been able to get an address to mail it to the resident's daughter for her to sign it through the mail. When asked if she documented the refusal of Resident #89 to sign the forms, she said she did not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/13/22 at 3:50 PM, Resident #89 said that he did not remember being asked to sign any forms. In an interview on 09/13/22 at 4:02 PM, the Administrator and DON both said they expected the MDS Coordinator to follow procedures. The DON said the NOMNC and SNF ABN forms should have been signed. There should have been documentation about the resident refusing to sign the forms. Review of the facility's policy and procedure Form Instruction for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, not dated, revealed the following [in part]: Provider Delivery of the NOMNC: The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift on a daily basis. Residents Affected - Many The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs. The facility's failure could affect the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily. The findings included: Observations on 09/11/22 at 11:30 AM revealed the daily nursing staff hours posted on the wall outside of the DON's office was dated 09/09/22. Observation on 09/12/22 at 11:30 AM revealed the daily nursing staff hours form was posted on the wall outside of the DON's office but did not have the actual hours worked by licensed and unlicensed direct care staff and the posted resident census was 119 but the actual census was 115. Observation on 09/13/22 at 10:30 AM revealed the daily nursing staff hours form was posted on the wall outside of the DON's office but did not have the actual hours worked by licensed and unlicensed direct care staff and the and the posted resident census was 119 but the actual census was 115. Review of the Facility's Daily Nursing Staffing Report form, dated 09/11/22, 09/12/22 and 09/13/22, revealed it documented the numbers of scheduled staff for each shift but not the actual staff for each shift, including RNs, LVNs, CMA's and CNAs. The form also documented an incorrect in-house resident census for each day observed. In an interview on 9/13/22 at 8:45 AM, the DON stated she did not know the forms needed to include documentation of the actual staff hours worked each shift, and the census each shift. She further stated, I'm not sure what the facility policy and procedure was for daily nursing staff posting She stated she just knew they were supposed to post it daily. She stated she would look for a policy and procedure. In an interview on 9/13/22 at 9:45 AM, the ADON stated, I'm not sure what the facility policy and procedure was for daily nursing staff posting or who is responsible for posting it. Record Review of the facility's undated policy for Nurse Staffing Posting Information revealed the following [in part]: Policy It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 1. The nurse staffing information will be posted on a daily basis and will contain the following information: Level of Harm - Potential for minimal harm a. Facility name b. The current date Residents Affected - Many c. Facility's current resident census at the beginning of the shift for which the information is posted. d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: I. Registered Nurses II. Licensed Practical Nurses/Licensed Vocational Nurses III. Certified Nurse Aides IV. Certified Medication Aides 2. The facility will post the nurse staffing data at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents and visitors. 4. Nursing schedules and posting information will be maintained in the Human Resources Department for review for at least 24 months or according to state law, whichever is greater FACILITY FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure discontinued medications were secured on 1 of 1 medication rooms reviewed for pharmacy services. The facility did not ensure medications were secured. The DON did not require that medications that had been discontinued were in a secure medication room away from un-licensed personnel until destroyed. This failure could place the residents who resided in the facility at risk of a drug diversion. Findings included: During an observation on [DATE] at 2:05 PM, The Medical Records room which held the resident's records, contained various discontinued prescription medications. The medications were located on the floor in a large hazmat box that was accessible to un-licensed personnel. During an interview on [DATE] at 3:35 PM with the DON, revealed that it was not stored accurately and that all medications once discontinued should be locked to un-licensed employees. When asked, she said that there was other unlicensed personnel that had access and authorization to be in the medical record room. She said that she was responsible for the training and overseeing discontinued meds. A printed TAC policy that was used as the facility policy, dated on [DATE], titled, Texas Administrative Code states, (g) Mediations of deceased residents, medications that have passed the expiration date, and medications that have been discontinued must be securely stored and reconciled. These medications must be disposed of according to federal and state laws or rules on a quarterly basis. Discontinued drugs may be reinstated if reordered prior to destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to distribute and serve food in accordance with professional standards for food service safety. Dietary Aide at satellite dining area during lunch handled and plated the resident's bread rolls using un-sanitized gloves while touching potentially contaminated surfaces such as the food cart used to transport food, countertops and chafing dish handles. This failure could place residents at risk for acquiring food-borne illnesses. Findings include: 9/11/2022 beginning at 12:40 PM. Observation of lunch service at the satellite dining area revealed DA #1 plating food from several heated trays (chafing dishes) to 18 residents waiting to be served. DA #1 was picking up dinner rolls and putting them on each resident's plate using gloved hands only, without changing them. DA #1 also moved three desserts using gloved hands, without changing them, from hard dishes to disposable ones for residents who were in their room under contact isolation. DA #1 touched other surfaces that were potentially contaminated such as counter tops, handles, food cart and other items nearby throughout the entire process. 9/12/2022 at 12:07 PM. Observed a resident in the satellite dining area who was sitting in her wheelchair lift open several of the chafing dishes to see if there was any food in them prior to the meal being served. 9/12/2022 beginning at 12:15 PM. Observation of lunch service at the satellite dining area revealed DA #1 using gloved hands and no utensils to pick up dinner rolls and place them on resident food plates. DA #1 was touching a variety of potentially contaminated surfaces throughout, such as, counter tops, food service cart, handles of heating trays (chafing dish) and other items nearby. 9/12/2022 at 2:30 PM. In an interview with DM and CC, both said that DA #1 should have used either a dedicated hand with a clean glove or tongs to pick up and transfer food. Using unclean, unchanged gloved hands are unacceptable. 9/12/2022 at 3:05 PM. Administrator said that picking up food with gloved hands is unacceptable and disciplinary action will be in place. 9/13/2022 at 1:45 PM. Record review of a facility document titled Department: Nutrition Services; Policy No: 4.03; Effective Date: 1/1/2010; Page 4-4; Subject: Indications for Glove Use; Section: Sanitation revealed the following: o Policy: The 2009 Food Code states that food employees shall minimize bare hand contact with exposed food that is not in a ready-to-eat form. Food employees serving a highly susceptible population, such as nursing home residents, may not contact ready-to-eat food or food that will not be subsequently cooked with their bare hands and shall use suitable utensils such as [NAME] tissue, spatulas, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 tongs, single-use gloves or dispensing equipment. Level of Harm - Minimal harm or potential for actual harm o Residents Affected - Some Procedure: Number (#) 6. Gloves are changed whenever an un-sanitized item or surface is touched. Examples included: opening a drawer, touching a dirty plate, opening a trash can with hands, turning on a faucet, touching a resident and after sneezing, coughing, or touching the face or hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #'s 79, 321 and 371) reviewed for medication administration. Resident #79's Medication Administration Record (MAR) reflected the administration of Hydrocodone-Acetaminophen (a medication used to treat pain) was not accurately documented in the electronic medication record. Resident #321's Medication Administration Record (MAR) reflected the administration of Hydrocodone-Acetaminophen (a medication used to treat pain) was not accurately documented in the electronic medication record. Resident #371's Medication Administration Record (MAR) reflected the administration of Oxycodone (a medication used to treat pain) was not accurately documented in the electronic medication record. This deficient practice placed residents who receive medications from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications due to inaccurate documentation of administration. Findings include: Review of Resident #79's face sheet for September 2022 revealed the following diagnoses: Cerebral Infarction (disrupted blood flow to the brain), dysphagia (difficulty swallowing) and pain. Review of Resident #79's September 2022 Physicians Orders for EMAR and Controlled Substance disposition record revealed Hydrocodone-Acetaminophen 5/325mg tablet: Give 1 by mouth every 6 hours as needed for pain. EMAR and controlled substance disposition record reflected the following administration by nursing staff: -September 1, 2022, at 2000 (8:00 PM) revealed the medication was administered but was not documented in the EMAR. -September 3, 2022, at 0708 (7:08 AM) revealed the medication was administered but was not documented on the controlled substance disposition record. -September 2, 2022, at 2036 (8:36 PM) revealed the medication was administered but was not documented in the EMAR. -September 6, 2022, at 1200 (12:00 PM) revealed the medication was administered but was not documented in the EMAR. -September 8, 2022, at 1715 (5:15 PM) revealed the medication was administered but was not documented in the EMAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm -September 10, 2022, at 0940 (9:40 AM) revealed the medication was administered but was not documented in the EMAR. -September 10, 2022, at 01740 (5:40 PM) revealed the medication was administered but was not documented in the EMAR. Residents Affected - Some -September 11, 2022, at 1400 (2:00 PM) revealed the medication was administered but was not documented in the EMAR. -September 12, 2022, at 1650 (4:50 PM) revealed the medication was administered but was not documented in the EMAR. Review of Resident #321's face sheet for September 2022 revealed the following diagnoses: Alzheimer's, Anxiety and low back pain. Review of Resident #321's September 2022 Physicians Orders for EMAR and Controlled Substance disposition record revealed Hydrocodone-Acetaminophen 10/325mg tablet: Give 1 by mouth every 6 hours as needed for pain. EMAR and controlled substance disposition record reflected the following administration by nursing staff: -September 7, 2022, at 1500 revealed the medication was administered but was not documented in the EMAR. -September 8, 2022, at 0835 revealed the medication was administered but was not documented in the EMAR. -September 9, 2022, at 0810 revealed the medication was administered but was not documented in the EMAR. -September 9, 2022, at 1210 revealed the medication was administered but was not documented in the EMAR. -September 10, 2022, at 0840 revealed the medication was administered but was not documented in the EMAR. -September 10, 2022, at 2000 revealed the medication was administered but was not documented in the EMAR. -September 11, 2022, at 0900 revealed the medication was administered but was not documented in the EMAR. -September 11, 2022, at 1700 revealed the medication was administered but was not documented in the EMAR. -September 11, 2022, at 2100 revealed the medication was administered but was not documented in the EMAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm -September 12, 2022, at 1700 revealed the medication was administered but was not documented in the EMAR. Review of Resident #371's face sheet for September 2022 revealed the following diagnoses: Heart Disease, Neoplasm of breast (breast cancer). Residents Affected - Some Review of Resident #371's September 2022 Physicians Orders for EMAR and Controlled Substance disposition record revealed Oxycodone 5mg tablet: Give 1 by mouth every 4 hours as needed for pain. EMAR and controlled substance disposition record reflected the following administration by nursing staff: -September 9, 2022, at 0536 (5:36 AM) revealed the medication was administered but was not documented on the controlled substance disposition record. -September 10, 2022, at 0915 (9:15 AM) revealed the medication was administered but was not documented in the EMAR. -September 10, 2022, at 1900 (7:00 PM) revealed the medication was administered but was not documented in the EMAR. -September 11, 2022, at 0650 (6:50 AM) revealed the medication was administered but was not documented in the EMAR. -September 11, 2022, at 1736 (5:36 PM) revealed the medication was administered but was not documented in the EMAR. -September 11, 2022, at 2115 (9:15 PM) revealed the medication was administered but was not documented in the EMAR. -September 12, 2022, at 0949 (9:49 AM) revealed the medication was administered but was not documented in the EMAR. -September 13, 2022, at 0930 (9:30 AM) revealed the medication was administered but was not documented in the EMAR. -September 13, 2022, at 1114 (11:14 AM) revealed the medication was administered but was not documented on the controlled substance disposition record. During interview on 09/13/2022 at 3:58 PM the Director of Nurses (DON) stated that the person administering the medication should document that it was administered and any vital signs or refusal of the resident to take the medication. She said this was not done according to policy and procedures and that she would be completing in-service immediately to correct the issue. She said that all staff will sign out the medication in the EMAR at the same time they are signing it out on the controlled substance disposition record. She said that LVN #2 failed to do this due to getting busy. She said that she was responsible for training and that she was monitoring medications by the count sheet, which always came up accurately. She said that the failure could result in additional doses given before the are scheduled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm During interview on 09/13/2022 at 4:12 PM with LVN #2, she said that she got busy, and she forgot to sign them out of the computer and that this was not an error she does often. She said that she had been trained accurately on medication administration and documentation. She said that she has never had a medication administered inaccurately or a medication count sheet be incorrect. She said that she has received additional training on medication administration since the issue was identified. Residents Affected - Some Review of a current facility policy with (no date) titled Administration of Drugs reflected the following elements: 12. Make appropriate entry on E-MAR and Narcotic Controlled Sheet, if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Potential for minimal harm Based on record review and interview, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis in that: Residents Affected - Many The facility did not have a qualified social worker since 08/01/2022. This failure could affect any residents in need of social services at risk of psycho-social decline and poor-quality of life. Findings include: Record review of the Facility Summary Report revealed the facility had a maximum capacity of 130. In an interview with the unlicensed Social Worker, on 09/13/22 at 10:02 AM, she said she recently graduated from school with a degree in Social Work but she had not tested for or received her social worker license. She said she is not being overseen by anyone but can reach out to a Social Worker at a sister facility if she has any questions. In an interview with the Administrator, on 09/13/22 at 10:30 AM, he said the last Social Workers last day at the facility was at the end of July 2022 and the current Social Worker started on 08/01/22. The Social Worker was fresh out of school and did not have her license to practice social work. He said he thought the Social Worker had 9 months to get her license. The Administrator did not know the Social Worker had to be licensed at the time of hire. Record review of facility policy Operational/Resident Care Policies, V.5., not dated, revealed the following [in part]: Social Services Director: The Social Service Program is directed by either a full-time qualified Social Worker or a qualified Social Worker is contracted to provide social services at a sufficient amount of time to meet the needs of the residents. The qualified Social Worker will be licensed by the Texas State Board of Social Worker Examiners and have a bachelor's degree in Social Work and one year of supervised social work in a health care setting working directly with individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection control program that provided a safe and sanitary environment to help prevent the spread of infections, in that: Residents Affected - Some Dietary Aide at satellite dining area handled and plated bread rolls using un-sanitized gloves while touching potentially contaminated surfaces such as the food cart used to transport food, countertops and chafing dish handles. This failure place residents at risk for acquiring food-borne illnesses as well as diseases transmitted via contaminated surfaces. Findings include: 9/11/2022 beginning at 12:40 PM. Observation of lunch service at the satellite dining area revealed DA #1 plating food from several heated trays (chafing dishes) to 18 residents waiting to be served. DA #1 was picking up dinner rolls and putting them on each resident's plate using gloved hands only. DA #1 also moved three desserts using gloved hands from hard dishes to disposable ones for residents who were in their room under contact isolation. DA #1 touched other surfaces that were potentially contaminated such as counter tops, handles, food cart and other items nearby throughout the entire process. 9/12/2022 at 12:07 PM. Observed a resident in the satellite dining area who was sitting in her wheelchair lift open several of the chafing dishes to see if there was any food in them prior to the meal being served. 9/12/2022 beginning at 12:15 PM. Observation of lunch service at the satellite dining area revealed DA #1 using gloved hands and no utensils to pick up dinner rolls and place them on resident food plates. DA #1 was touching a variety of potentially contaminated surfaces throughout, such as, counter tops, food service cart, handles of heating trays (chafing dish) and other items nearby. 9/12/2022 at 2:30 PM. In an interview with DM and CC, both said that DA #1 should have used either a dedicated hand with a clean glove or tongs to pick up and transfer food. Using unclean gloved hands are unacceptable. 9/12/2022 at 3:05 PM. Administrator said that picking up food with gloved hands is unacceptable and disciplinary action will be in place. 9/13/2022 at 1:45 PM. Record review of a facility document titled Department: Nutrition Services; Policy No: 4.03; Effective Date: 1/1/2010; Page 4-4; Subject: Indications for Glove Use; Section: Sanitation revealed the following: o Policy: The 2009 Food Code states that food employees shall minimize bare hand contact with exposed food that is not in a ready-to-eat form. Food employees serving a highly susceptible population, such as nursing home residents, may not contact ready-to-eat food or food that will not be subsequently cooked with their bare hands and shall use suitable utensils such as [NAME] tissue, spatulas, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 tongs, single-use gloves or dispensing equipment. Level of Harm - Minimal harm or potential for actual harm o Residents Affected - Some Procedure: Number (#) 6. Gloves are changed whenever an un-sanitized item or surface is touched. Examples include: opening a drawer, touching a dirty plate, opening a trash can with hands, turning on a faucet, touching a resident and after sneezing, coughing, or touching the face or hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 16 of 16

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0565GeneralS&S Epotential for harm
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0732GeneralS&S Cno actual harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0850GeneralS&S Cno actual harm
F850 - Social worker
Hire a qualified full-time social worker in a facility with more than 120 beds.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the September 13, 2022 survey of SHERIDAN MEDICAL LODGE?

This was a inspection survey of SHERIDAN MEDICAL LODGE on September 13, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SHERIDAN MEDICAL LODGE on September 13, 2022?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 13, 2022