Majestic Care of Sheridan: Dangerous Blood Sugar Ignored - IN
The medication records at Majestic Care of Sheridan show eight separate instances where staff documented dangerously abnormal blood sugar readings for Resident 65, then marked "N" for no physician notification. The readings included levels low enough to cause unconsciousness and high enough to trigger diabetic coma.
Resident 65 lives with type two diabetes, hypertension, and dementia. A physician's order from April 3, 2025 required staff to check blood sugar four times daily and notify the provider if readings fell below 90 or rose above 350.
The medication administration record tells a different story.
On December 26, 2025, staff recorded a blood sugar of 85. No doctor called.
Two days later, the reading dropped to 74. Still no notification.
On December 31, the pendulum swung violently in the other direction — 368, well into dangerous territory. The "N" remained in the notification column.
January 18 brought another critical high of 367. March delivered a string of lows: 80 on February 19, then 83, 82, and 84 on consecutive days in mid-March. Each time, staff checked the box indicating no physician was contacted.
Blood sugar levels below 70 can cause confusion, seizures, and loss of consciousness. Readings above 350 put diabetics at risk for diabetic ketoacidosis, a potentially fatal condition where the body begins breaking down fat for energy and producing toxic acids.
The facility's own care plan, dated April 2, 2025, acknowledged Resident 65 faced risks from both hypoglycemia and hyperglycemia. The intervention specified staff should "obtain blood sugars as ordered and document and notify the physician of abnormal findings."
They documented. They didn't notify.
When inspectors interviewed the Executive Director on April 9, she offered a partial explanation. If the physician happened to be in the building when staff took an abnormal reading, she said, the nurse would have notified the doctor and written a progress note about it.
But Licensed Practical Nurse 2 contradicted that account during her interview the same day. When "N" appeared on the medication record, she told inspectors, the physician would not have been notified.
The Executive Director couldn't locate any documentation showing doctors had been told about Resident 65's dangerous blood sugar levels. The next day, she revealed another gap: the facility had no policy for physician notification or call orders.
No policy meant no clear protocol for when nurses should pick up the phone. No documentation meant no proof they ever did.
The physician's order couldn't have been clearer. Four blood sugar checks daily. Call if it's under 90 or over 350. The medical necessity was obvious — Resident 65's diabetes required constant monitoring to prevent life-threatening complications.
Instead, staff created a paper trail of negligence. Eight abnormal readings. Eight missed opportunities to prevent a medical emergency. Eight times they followed half the order and ignored the other half.
The pattern suggests systemic failure rather than isolated mistakes. From late December through mid-March, multiple staff members across different shifts made the same choice: check the blood sugar, write down the dangerous number, mark "no" for doctor notification.
Resident 65's dementia meant they likely couldn't advocate for themselves when symptoms of high or low blood sugar emerged. The facility's care plan recognized this vulnerability, explicitly stating the need for staff vigilance and physician communication.
That protection failed repeatedly over three months.
The inspection found minimal harm occurred, but the potential for serious consequences was clear. Diabetic emergencies can develop rapidly, especially in elderly residents with multiple health conditions. Quick medical intervention often determines whether a patient recovers fully or suffers permanent damage.
Majestic Care of Sheridan left Resident 65 exposed to that risk eight documented times, with no policy to prevent it from happening again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Sheridan from 2026-04-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
MAJESTIC CARE OF SHERIDAN in SHERIDAN, IN was cited for violations during a health inspection on April 10, 2026.
The readings included levels low enough to cause unconsciousness and high enough to trigger diabetic coma.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at MAJESTIC CARE OF SHERIDAN?
- The readings included levels low enough to cause unconsciousness and high enough to trigger diabetic coma.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SHERIDAN, IN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MAJESTIC CARE OF SHERIDAN or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 155376.
- Has this facility had violations before?
- To check MAJESTIC CARE OF SHERIDAN's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.