Sharon Health Care Elms

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin for one (R1) of three residents reviewed for incidents/accidents.

Inspectors wroteBased on interview and record review the facility failed to investigate an injury of unknown origin for one (R1) of three residents reviewed for incidents/accidents.

Inspectors wroteBased on interview and record review, the facility failed to act quickly to get medical care for one (R1) of three residents reviewed for injuries in a sample of four. This failure resulted in R1 continuing to be in pain at the nursing home after an incident that caused facial and body bruising for four and a half hours before the emergency personnel were summoned to the nursing home.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for reducing falls and using a portable lifting machine for one (R1) of three residents reviewed for accident/incidents in a sample of four. This failure resulted in R1 sustaining multiple bruises to her face and body, and pain which required R1 to be transferred to the hospital.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident received adequate supervision and dietary management to prevent a choking incident for one of three residents (R2) reviewed for choking in the sample of six. These failures resulted in the resident (R2) consuming food inconsistent with his prescribed mechanical soft diet, leading to a fatal choking event at the facility. These failures resulted in an Immediate Jeopardy that began on 7/23/25. While the Immediate Jeopardy was removed on 12/17/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date multi-use medications upon opening, discard expired medications, and double lock controlled substances for seven residents (R7, R8, R9, R10, R11, R12, R13) reviewed for medication storage in a sample of 13. Findings Include:The facility's Storage of Medications policy (not dated) documents, No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with our established procedures governing the destruction of medication. 14. All controlled substances must be stored under double lock and key. The facility's Labeling of Drugs and Medications policy (not dated) documents, All drugs and biologicals must be properly labeled and legible at all times. 11. f. Other as appropriate or necessary. [...]

Inspectors wroteBased on interview and record review the facility failed to follow Physician ordered wound treatments and implement Registered Dietician recommendations for wound healing for one (R1) of three residents reviewed for pressure ulcers in a sample of 13. Finding Include:The facility's Physician's Order Policy (not dated) documents, The purpose of this policy is to establish guidelines for the ordering, processing, and management of physician's orders in a long-term care facility, ensuring compliance with State and Federal regulations, and promoting the health and safety of residents. Order implementation, orders must be implemented promptly by licensed nursing staff according to the facility's protocols. [...]

Inspectors wroteBased on interview and record review the facility failed to follow Registered Dietician recommendations to obtain weekly weights to monitor for and prevent further weight loss for one (R1) of four residents reviewed for nutrition in a sample of six.

Inspectors wroteBased on interview and record review the facility failed to maintain an Infection Control log for June, July, August and September of 2025. This failure has the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain one resident's (R23) room in good repair of 24 residents' rooms observed during the initial tour for maintenance in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure weights were obtained and the physician was notified of weight gains per Physicians Order. The facility also failed to monitor weights for discrepancies for one of three residents (R19) with daily weights in a sample of 28.

Inspectors wroteBased on interview, observation, and record review the facility failed to initiate Enhanced Barrier Precautions for two residents (R66, R2) out of five residents reviewed in a total sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately supervise a resident (R1) to prevent resident-to-resident physical abuse for five of five residents (R1-R5) reviewed for abuse in the sample of five. These failures resulted in R1 punching R2 in the left eye, causing a hematoma under R2's left eye and bruising surrounding R2's left eye, and R1 punching R5 in the right arm, causing R5 right arm pain for three days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety after a transfer and failed to keep a resident free from injury for one of three residents (R1) reviewed for accidents/injuries in a sample of four. This failure resulted in R1 sustaining pain, bruising and a hospital visit with fractures to the left ankle and foot.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene and glove changes during pressure ulcer treatments. The facility also failed to ensure pressure ulcer treatments were completed as ordered. These failures effect three of three residents (R2, R3, R4) reviewed for pressure ulcers in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer a resident with the required mechanical lift, for one of three residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1 falling twice and during the second fall sustaining a periprosthetic distal left femur fracture, ongoing pain, and psychosocial fear of being transferred with a mechanical lift.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to conduct a resident assessment to determine the resident's degree of mobility, physical impairment and the proper transfer method needed once a resident experienced increased weakness. The facility also failed to maintain an adequate working electrical supply to adjust an electric bed into the lowest position prior to a transfer for one resident (R9) and failed to implement appropriate fall interventions for one resident (R8.) These failures affect two of three residents (R8, R9) reviewed for falls in the sample of 27. These failures resulted in R9 losing grip of the sit-to-stand mechanical lift handles and falling to the floor, sustaining a coccyx fracture and severe pain that required hospitalization. B. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a bed hold notification to the resident or resident representative for four of four residents (R6, R9, R11, R46) reviewed for hospital transfers in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to develop a Care Plan for pain for one resident (R4) of 24 residents reviewed for pain in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to provide monitoring and documentation of dialysis access site observations, failed to provide communication with the dialysis center, failed to identify type of dialysis access site/device, failed to provide a current/valid dialysis contract and failed to develop and implement a policy and procedure for residents receiving offsite dialysis for one resident (R60) of one resident reviewed for Hemodialysis in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all controlled medications (schedule II medications) in a secured locked box in the medication cart and failed to destroy all controlled medications once discontinued for four of four residents (R1, R2, R3, R4) reviewed for medication storage in the sample of four.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately remove a staff member that was accused of abuse. This failure has the potential to affect all 73 residents who currently reside in the facility. Findings Include: The Facility's Abuse Prevention Program dated 2011 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to immediately report an allegation of abuse for one resident (R1) of three residents reviewed for abuse. Findings Include: The Facility's Abuse Prevention Program dated 2011 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a clinical indication for use of an indwelling catheter for one resident (R1) of three residents reviewed for catheters. Findings Include: The Facility's Indwelling Catheter Insertion policy dated 03/00 documents Indications should be evaluated before insertion of an indwelling catheter and reevaluated quarterly. These indications are: the resident is in a coma or has terminal illness; a stage 3 or 4 pressure ulcer in an area affected by the incontinence; untreatable urethral blockage; the need for exact measurement of urine output; a history of being unable to void after having a catheter removed in the past or a resident with a quad or paraplegia who failed a past attempt to remove a catheter. [...]

Inspectors wroteA. Based on observation, record review and interview, the facility failed to ensure appropriate precautions were utilized to prevent cross contamination, failed to properly don an N95 mask (respirator), failed to fit test employee annually for N95, failed to wear an N95 in the patients room per policy. These failures have the potential to affect all 73 residents residing in the facility. These failures resulted in three deficient practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a designated infection preventionist. This failure has the potential to affect all 73 residents within the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure pain was assessed per policy for 3 of 3 residents (R20, R30, R61) reviewed for pain.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was treated in a dignified manner for one of one resident (R51) reviewed for dignity in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the residents needs with a TV (television) for 1 of 36 residents (R30) reviewed for accommodation of needs in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician was notified when a resident developed a full body rash for one of one resident (R52) reviewed for notification of changes in a sample of 36.

Inspectors wroteBased on interview and record review the facility failed to ensure a care plan with interventions was developed to address a residents' limitation in range of motion for one of 36 residents (R11) reviewed for care plans in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly clean a resident during incontinence care and failed to perform hand hygiene between incontinence care tasks for one of one resident (R51) reviewed for incontinence care in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with limitations in range of motion received range of motion services which affected one of eight residents (R11) reviewed for range of motion in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a floor mat was in place as ordered for 1 of 2 resident (R61) reviewed for falls in a sample of 36.

Inspectors wroteBased on observation and interview the facility failed to ensure a urinary indwelling catheter bag was placed in a dignity bag for one (R49) of two residents reviewed for indwelling catheters in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was provided with tube feedings and water as ordered by the physician for one (R10) of five residents reviewed for nutrition and hydration in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to document resident behaviors to warrant the use of antipsychotic medications and failed to document targeted behaviors for the use of antipsychotic medications for two (R33 and R45) of five residents reviewed for unnecessary medications in the sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to treat, monitor, and prevent new and worsening pressure ulcers that required surgical debridement for one (R69) of five residents reviewed for pressure ulcers in a sample of 26. This failure resulted in house acquired pressure ulcers and worsening pressure ulcers, that required surgical debridement for R69.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate and prevent multiple injuries for one resident (R44) of three residents reviewed for wounds from injury in the sample of 26. This failure resulted in an infection of an elbow wound requiring antibiotics and isolation precautions. The facility also failed to use the assessed number of individuals needed to transfer residents for two residents (R57 and R322) of eight residents reviewed for falls in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep dietary worker certifications up to date. This failure has the potential to affect all 68 residents who consume food in the facility except R15 who NPO is (Nothing by Mouth).

Inspectors wroteBased on observation, interview and record review, the facility failed to notify a resident's representative of significant changes in weight (R30, R33, R44, R68) and accidents causing changes in skin integrity (R44) for four of four residents reviewed for changes in condition in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered by the physician for one resident (R53) in the sample of five residents reviewed for medication administration. This failure resulted in two medication errors out of 35 opportunities for error, for a 5.71% error rate.