Health inspection·February 16, 2024

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 observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3(Resident #1, Resident #5 and Resident #6) of 3 residents reviewed for infection control. techniques in that: Residents Affected - Some 1. The facility failed to ensure the 200 hall CNA E washed or sanitized her hands in between rooms or between feeding the following: Resident #6 and entering room and setting up Resident #1's food tray; after setting up Resident #1's room tray CNA E left Resident #1's room to set up tray for Resident #5. 2. The facility failed to ensure that 200 hall CNA E sanitized her hands or donned gloves when touching Resident #5's potato. 3. The facility failed to ensure the 200 hall MA C washed or sanitized her hands or donned gloves prior to feeding Resident #6. These failures could place residents at risk of infections. The findings included: 1. Record review of Resident #1's face sheet, dated 2/16/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included muscle weakness and paraplegia (paralysis of lower body typically caused by spinal injury or disease). 2. Record review of Resident #5's face sheet, dated 02/16/2024, revealed Resident #5 was an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of which included Dysphagia follow other cerebrovascular disease (difficulty swallowing) and hypertension (high blood pressure). 3 Record review of Resident #6's face sheet, dated 2/16/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (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 2 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 02/16/2024 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)