Sharon Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to provide toileting assistance to 2 of 5 sampled residents (Resident 1 and Resident 2) reviewed for Activities of Daily Living (ADL) care. This failure placed residents at risk of skin infections, low dignity, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 3 kitchen refrigerators, and in 1 of 2 nourishment refrigerators (East Hall) reviewed for food storage. The facility also failed to keep an accurate temperature log for 1 of 2 nourishment refrigerators (East Hall). These failures placed residents at risk for food borne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 59) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident admission Minimum Data Set (MDS, an assessment tool) was completed within the required timeframe for 1 of 10 sampled residents (Resident 59) reviewed for resident admission assessments. Failure to complete the admission MDS within the required timeframe placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission and Resident Review (PASRR) assessment was reviewed, completed and submitted for 2 of 5 residents (Resident 16 and Resident 4) reviewed for PASRR. This failure had the potential to place residents at risk of not receiving the necessary mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 3) reviewed for accidents related to falls. This failure placed residents at risk for subsequent falls, injuries, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain daily weights per physician's orders for 1 of 5 residents (Resident 5) reviewed for quality of care. The facility also failed to check for PICC (peripherally inserted central catheter line used for long-term intravenous (IV) access to administer medications) line blood return for 1 of 1 resident (Resident 23) reviewed for medication administration. This failure placed residents at risk of unmet care needs, potential complications and a diminished quality of life. Weights Resident 5 was admitted to the facility on [DATE] with multiple diagnoses to include congestive heart failure. The admission /Medicare - 5 Day Minimum Data Set (an assessment tool), dated 06/20/2025, documented Resident 5 was severely cognitively impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete pain assessments every shift for 1 of 5 residents (Resident 6) reviewed for pain. This failure placed residents at risk for unmet care needs and a diminished quality of life. Resident 6 was admitted to the facility on [DATE], with multiple diagnoses to include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), fibromyalgia (chronic condition characterized by widespread muscle pain) and chronic pain syndrome. The Quarterly Minimum Data Set (an assessment tool), dated 05/02/2025, documented Resident 6 was severely cognitively impaired. Record review of Resident 6's Nightingale Pain Assessment: Verbal & Non-verbal, dated 08/25/2025, documented Resident 6 occasionally experienced pain and staff assessment for pain should have been conducted. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment was maintained for 2 of 7 rooms (rooms [ROOM NUMBERS]) reviewed for environment, when sharps containers (a puncture-resistant, leak-proof container designed to safely collect and dispose of sharp medical instruments that can puncture or cut skin, like needles, syringes, and lancets) were observed above the full line. This failure placed residents, visitors, and staff at risk for injury, potential exposure to diseases, and a diminished quality of life. Findings Included . In an observation on 09/08/2025 at 11:07 AM, the red sharps container mounted on the wall inside of room [ROOM NUMBER], date written on container 09/16/24, showed sharps instruments inside of the container above the fill line that said, do not fill above this line. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the survey result binder included the health recertification and complaint survey results for 2 of 3 years (2024 and 2025) reviewed for availability of survey reports. This failure prevented residents, resident representatives, family members, and visitors from exercising their right to review past survey results.

Inspectors wroteBased on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 4 of 9 sampled residents (1, 24, 26 & 30) reviewed for ADs. This failure place residents at risk for losing their right to have healthcare preferences and decisions honored and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for 2 of 4 sampled residents (3 & 288) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 for 1 sampled resident (26) reviewed for transfer notice requirements. This failure placed residents at risk of loss of added protection from being inappropriately transferred or discharged from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's oral/dental status for 1 of 1 sampled resident (21) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed for 1 of 4 sampled residents (6) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities of (ADLs) care was provided for dependent residents including nail care for 1 of 2 sampled residents (5) reviewed for ADLs. This failure placed residents at risk of not receiving the care and assistance needed for which they were unable to perform themselves.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner of which the resident and/or representative understood for 1 of 3 sampled residents (25) reviewed for arbitration agreement. This failure placed residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention practices are being maintained including proper use of personal protective equipment (PPE) and hand hygiene for 2 of 8 sampled residents (26 & 30) reviewed for infection prevention and control. These failures placed residents at risk of communicable infections and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure mail delivery was provided on Saturdays for residents receiving mail via the US Postal Service for 4 of 5 sampled residents (7, 12, 19 & 246) reviewed for communication with privacy. This failure placed residents at risk of not receiving their mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were prepared, stored, and served in a sanitary manner when the facility failed to ensure the kitchen was free from dust and debris, clean dishes and utensils were stored in a clean manner, and opened foods were not labeled and/or dated as required for all 42 facility residents who received meals from the facility kitchen. These failures placed all residents at risk for food-borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (foley catheter, a flexible tube inserted into the bladder to drain urine into a drainage bag), received appropriate care and services to minimize the risk of associated urinary infections for 4 of 5 sampled residents (10, 36, 24 & 1), and failed to ensure hand hygiene and glove changes were performed when indicated in the kitchen during tray line service by 1 of 3 sampled kitchen staff (Staff 0) reviewed for infection prevention and control. These failures placed the residents at risk for infections, medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 4 of 6 sampled residents (5, 12, 32 & 39) reviewed for right to be informed and make treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 4 of 14 sampled residents (39, 5, 8 & 36) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe environment was maintained and free from hazards related to unsecured and/or unsupervised chemicals and/or tools for 1 of 1 rooms under construction (Resident room [ROOM NUMBER]) and 1 of 2 shower rooms (West Hall) reviewed for accident hazards. This failure placed residents at risk for avoidable accidents and injuries, negative health outcome, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects, behaviors, and/or placing a stop date of 14 days for psychotropic as needed medications for 6 of 8 sampled residents (9, 15, 39, 5, 12 & 32) reviewed for unnecessary psychotropic medication. These failures placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were evaluated, assessed and a physician order was obtained for safe self-administration of medications for 1 of 1 sampled residents (24) reviewed for clinically appropriate self administration of medications. This failure placed residents at risk for medication errors, adverse medication interactions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD) for 1 of 6 sampled residents (7) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) was issued timely, at least two calendar days before Medicare services ended, for 1 of 3 sampled residents (33) reviewed for SNF ABN and NOMNC notification. This failure placed residents and their representatives at risk for not having adequate information to make financial decisions related to a continued stay in the facility and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was a system in place to resolve grievances (a resident concern or complaint) promptly for 1 of 2 sampled residents (7) reviewed for grievances. This failure paced residents at risk for unmet care needs, not being heard and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders and consents were obtained for 2 of 7 sampled residents (1 & 36) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 3 sampled residents (8) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessment data was encoded and transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 of 2 sampled residents (30) reviewed for resident assessments. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 14 sampled residents (10 & 32) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the bowel protocol was initiated per physician's orders and when needed for 1 of 7 sampled residents (12) reviewed for quality of care related to bowel management. This failure placed residents at risk for medical complications, change in health status, increased pain and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) had a valid medical diagnosis and a complete provider order for 1 of 5 sampled residents (8) reviewed for catheter use. This failure placed residents at risk of acquiring potentially preventable catheter associated urinary tract complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an anticoagulant (blood thinner) medication related complications were monitored for 1 of 3 sampled residents (5) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life.