Health inspection·March 29, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 2 of 3 residents (Resident #'s 1 and 4) reviewed for plan of care revision. The facility failed to include in the care plan a right foot brace/pose brace for Resident #1. The facility failed to include in the care plan, Behavioral Interventions for Resident #4. This failure could place the residents at risk of decline in health status and unmet physical and psychosocial needs due to the staff and providers not having the most current information for the Resident's plan of care. Findings include: Record review of Resident # 1's face sheet dated 3/28/24 revealed he was an [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: osteoarthritis, unsteadiness on feet, muscle weakness, and lack of coordination. It was not updated to include the diagnosis of peroneal palsy and the associated symptom of right foot drop. Record review of Resident #1's physician orders dated 02/05/24 revealed the following: posey to right foot bootie at all times until AFO (ortho ankle foot orthosis) Brace arrives. The order was discontinued on 03/01/24. A physician order for the diagnosis of peroneal palsy (a mononeuropathy of the lower extremity that can be debilitating with symptoms ranging from mild sensory loss to severe pain and foot drop) was added 0n 02/14/24. Resident needs AFO brace to right ankle. Record review of physician orders dated 03/28/24 revealed: Resident has AFO brace to right foot remove and assess skin daily. Record review of Resident #1's electronic health record revealed the most recent comprehensive care plan dated 03/20/24 did not contain revisions for a Right foot brace. Record review of Resident #1's admission MDS dated [DATE] revealed the following: section C documented Resident # 1's BIMS was 15, section GG documented the resident was wheelchair bound, section I documented the resident had a diagnosis of other neurologic condition, and section O Restraint or brace assist was marked no. Interview and observation with Resident #1 on 3/28/24 at 12:30 PM revealed he was wearing the brace to his rt foot. He stated therapy did not always reapply the brace after his daily therapy session (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 03/29/2024 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)