Green House Living For Sheridan
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
felt the facility probably could use more staff.d. Interview with RN #1 on 11/19/25 at 9:36 AM revealed when
she entered the cottage on the day of the incident, the CNA reported the resident had fallen in the bathroom. The RN revealed when she entered the resident's room, she observed the resident had obtained
a hematoma to his/her head and s/he reported being on the floor for a while. She revealed her assessment of the resident, the resident requested to go to the bathroom, which she assisted him/her to do. At that time,
the resident reported s/he had taken him/herself to the bathroom previously and did not use his/her walker.
The RN revealed the resident was aware of what had happened, was at his/her cognitive baseline following
the fall, and vital signs were normal; however, she felt the resident should go to the hospital for evaluation due to his/her use of Plavix [antiplatelet]. Further interview revealed the resident did not normally use his/her call light, she did not hear any alarms, and the CNAs had reported rounding on the resident at 9 AM. e. Interview with CNA #1 on 11/19/25 at 9:58 AM revealed she was the CNA working with resident #1
on the day of the fall. She revealed she was unfamiliar with the resident and was told s/he was fairly independent. She revealed she was the staff member who found the resident on the floor, after she observed the call light was on. The CNA revealed when she entered the room, the resident was on the floor, leaning against the recliner, and s/he was bleeding from the left side of his/her head. She revealed
she notified the nurse and the other CNA, and they took over the resident's care.f. Review of the call light Call History log for resident #1 on 10/18/25 showed the emergency bathroom light was activated at 9:20 AM and cancelled at 9:57 AM, 36 minutes after activation. Further review showed the nurse call light was activated at 9:39 AM, 19 minutes after the emergency bathroom light, and it was cancelled 8 minutes later at 9:47 AM.g. Interview with the facility administrator on 11/19/25 at 11:55 AM revealed the emergency bathroom light was activated by a pull cord in the resident's bathroom and the nurse call light was the regular call light activated with a push button in the resident's room. She revealed previously, the emergency call light and the nurse call light had the same tone and staff could not differentiate one from the other. Further interview confirmed she would expect resident call lights to be answered immediately and the facility developed a plan for improvement after the incident occurred.2. The following Root Cause Analysis and Corrective Actions were implemented by the facility by 11/12/25 and verified during the survey:a.
Resident #1 was immediately assessed on site and transferred to the hospital for evaluation and treatment
on 10/18/25.b. Staff training was performed on 11/12/25.c. Tone of each call light type changed in the call light system on 11/12/25.d. Implementation of a Handoff tool on 11/12/25.e. Call light response time audits were implemented on 11/8/25.
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Green House Living for Sheridan in Sheridan, WY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Sheridan, WY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Green House Living for Sheridan or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.