A list of the most recent deficiencies for Majestic Care of Sheridan. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-02-06 | 2023-04-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-02-06 | 2023-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-02-06 | N |
| 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. | Health | 2023-01-11 | 2023-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-11 | 2023-02-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-11 | 2023-02-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Develop a communication plan. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-08-19 | 2020-09-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-11 | 2020-05-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-03-11 | 2020-05-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-03-11 | 2020-05-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-11 | 2020-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-11 | 2020-05-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-11 | 2020-05-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-11 | 2020-05-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-11 | 2020-05-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-03-11 | 2020-05-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-11 | 2020-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-11 | 2020-05-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have an externally vented heating system. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-14 | 2019-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-18 | 2019-02-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-01-18 | 2019-02-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-18 | 2019-02-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-18 | 2019-02-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-18 | 2019-02-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-18 | 2019-02-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-18 | 2019-02-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-18 | 2019-02-17 | N |
| 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. | Health | 2019-01-18 | 2019-02-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-01-18 | 2019-02-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-18 | 2019-02-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-18 | 2019-02-17 | N |
