Sharon Health Care Pines

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent abuse of five (R2, R4, R5, R6, R7) of 7 residents reviewed for abuse. This failure resulted in R1 picking up a chair and hitting R2 in the head causing R2 to go unconscious, sustaining a bleeding laceration to upper lip requiring sutures and sustaining a laceration to left side of head requiring three staples.

Inspectors wroteBased on interview and record review the facility failed to report a resident-to-resident abuse allegation to the state agency for one (R1) of seven residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent abuse for one (R2) of three residents reviewed for abuse in a total sample of ten. The facility's Abuse Prevention Program Policy revised 12/18/24 documents that the facility affirms the right of our residents to be free from abuse. R2's medical record documents R2 was admitted to the facility on [DATE] with diagnoses to include Alcohol Abuse, Diabetes, Anxiety Disorder, and Psychoactive Substance Abuse. R2's Nursing Progress Note dated 1/18/26 at 12:21 PM documents Resident in a physical altercation with peer, resident separated by staff, no injuries noted. R2's Brief Interview for Mental Status dated 3/10/26 documents a score of 14, indicating R2 has little or no or little cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate and implement safety interventions for a resident who was on a restricted pass due to impaired thought process and poor safety awareness to prevent an elopement, failed to ensure staff were educated on identifying residents with restricted passes to leave the facility, failed to assess a resident after elopement, and failed to educate staff or implement additional safety interventions once a resident eloped for three (R37, R72, and R75) of four residents reviewed for elopement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there are sufficient number of licensed nursing staff to provide care and supervision for dependent residents. This has the potential to affect all 110 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure a Registered Nurse was working eight consecutive hours in a twenty four hour period. This has the potential to affect all 110 residents residing in the facility. On 8/28/25 at 8:30 AM, V2 (Director of Nursing) provided all nurse timecard reports for 8/5/25 through 8/24/25. The timecard reports have no documentation of a registered nurse working eight consecutive hours on 8/12/25. On 08/28/2025 at 10:15 AM, V2 confirmed there was not a Registered Nurse working on 8/12/25. The facility's Center's for Medicare and Medicaid Services Long Term Care Application, dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to label, and date opened food items in the kitchen's refrigerator and freezer and discard expired food, ensure kitchen ceiling tiles/vents were kept clean, and ensure kitchen freezer was maintaining proper temperature. This failure has the potential to affect all 110 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure the facility maintained an effective pest control program. This has the potential to affect all 110 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 110 residents residing within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to document medications at the time of administration for nine of nine residents (R3, R4, R6, R8, R13, R15, R18, R61 and R89), reviewed for medication administration, in a sample of 40.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide physician ordered treatments to one of one resident (R108) reviewed for skin conditions in the sample of 40.

Inspectors wroteBased on observation, record review and interview, the facility failed to give medications as ordered by the physician to three residents (R4, R8 and R18) of eleven residents reviewed for medication pass. This failure resulted in three errors out of twenty-five opportunities for a 12% medication error rate.

Inspectors wroteBased on observation, interview and record review, the facility failed to date an opened bottle of insulin for two of two residents (R8 and R101) reviewed for insulin administration, in a sample of 40.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate medical record by documenting physician- ordered blood glucose testing for one of four residents (R101), reviewed for blood glucose monitoring, in a sample of 40.

Inspectors wroteBased on observation, interview and record review facility staff failed to disinfect a shared blood glucose monitoring machine after use for two of two residents (R8 and R103) reviewed for blood glucose monitoring, in a sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to report resident-to-resident physical abuse to the State Agency for one (R2) of four residents reviewed for abuse in a sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to investigate resident-to-resident physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11.

Inspectors wroteBased on record review and interview, the facility failed to protect a resident from physical abuse for two of four (R1 and R3) residents reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a complex fracture of the left hip requiring surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to notify local law enforcement of a resident-to-resident physical altercation resulting in an injury, for one of two residents (R1) reviewed for reporting abuse in a sample of four. The facility's Abuse Prevention Program Facility Procedures, reviewed 7/21/25, documents that the facility shall contact local law enforcement authorities (i.e., non-emergency police number or 911) in the following situations: Physical abuse involving physical injury inflicted on a resident by another resident, except in situations where the behavior is associated with dementia or developmental disability. R1's Progress Notes, dated 7/22/25, document that resident (R1) was involved in an altercation with a peer (R2) while outside on the smoking patio. (R1) was lying on the patio, stating his hip hurt. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident physical and sexual abuse and failed to implement abuse risk assessment and care plans for four of four residents (R1-R4) reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a left femoral neck fracture, requiring surgical intervention.

Inspectors wroteBased on interview and record review the facility failed to investigate an incident when residents were exposed to a toxic chemical and failed to follow their policy regarding Safety/Supervision related to Incidents/Accidents. The facility failed to perform and document an individual assessment after a resident was known to have been exposed to a toxic chemical for one of three residents (R2) reviewed for quality of care and treatment in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to protect a resident (R1) from mental and verbal abuse and failed to protect residents from further potential abuse. This failure resulted in residents experiencing emotional distress and persistent fear of V3 (Certified Nursing Assistant). This failure has the potential to affect all 102 residents who reside in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/19/25 at approximately 5:00 pm, when V3 (Certified Nursing Assistant/CNA) responded inappropriately to R1. V3 taunted R1 by sticking her tongue out at R1; calling R1's significant other ugly; and asking if R1 was going to fight V3. R1 experienced emotional distress and fear of V3. V3's termination was rescinded and V3 returned to work in the facility, leaving residents fearful. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from physical abuse by another resident (R1) for two of four residents reviewed for abuse in a sample of four. This failure resulted in R2 receiving sutures at the hospital for a facial laceration.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse for one (R6) of seven residents reviewed for abuse in the sample of seven. Findings Include: The Facility's undated Abuse Policy documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below, this includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. [...]

Inspectors wroteBased on record review and interview the facility failed to respond to repeated resident council concerns. This has the potential to affect all 96 residents who reside in the facility. Findings Include: The Facility's admission Packet contained information on Resident Council that documented At least once a month, the residents of this facility participate in Resident Council meetings to discuss the diverse matters of nursing home life. The officers of the resident council communicate any matters of concern to the facility's management. The staff at our facility and the Resident Council will work cooperatively to effectively address resident concerns and advice. Participation in the Resident Council is not mandatory, and any issues raised by the residents, whether at the Resident Council meeting or otherwise will be addressed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to prevent and monitor residents for Physical Abuse and Verbal Abuse for four (R1, R23, R59, and R66) of 32 Residents reviewed for Abuse in a sample of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to treat one resident (R91) with dignity and respect of 24 residents reviewed for dignity and respect in a total sample of 34. Findings Include: The Facility's undated Resident Dignity policy documents (This Facility) promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or individuality. Dignity means that in their interactions with residents, staff carry out activities which assist the resident to maintain and enhance his/her self esteem and self worth. For example: [...]

Inspectors wroteBased on record review and interview the facility failed to assist one resident (R93) to find an alternate nursing home placement of 20 residents reviewed for discharge planning in a total sample of 34. Findings Include: The Facility's admission Packet includes the following Discharge Planning information The Social Service Department is the department dedicated within the facility to assist with discharge planning. The resident or family should contact Social Service as soon as the option of leaving the facility is being considered. It is the philosophy of this facility to help residents make transition to alternative living arrangements as smooth as possible. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a Preadmission Screening and Resident Review/PASARR including an initial Omnibus Budget Reconciliation Act/OBRA were revised for 2 of 2 residents (R8, R67) who were diagnosed with a psychiatric condition after admission in the sample of 34.

Inspectors wroteBased on record review and interview the facility failed to update one resident's chart (R99) for a code status change from Full Code to Modified DNR (Do Not Resuscitate). This failure resulted in R99 receiving full CPR including chest compressions after being found unresponsive. Findings Include: R99's POLST (Physician Order Life Sustaining Treatment) dated [DATE] documents Modified DNAR (Do Not Attempt Resuscitation) to include: non-invasive airway and breathing, IV (Intravenous medications) and transfer to the hospital. Do Not perform chest compressions. R99's care plan dated [DATE] documents (R99) wishes to be full code. R99's care plan was updated on [DATE] (one day after her death) to (R99) has DNR (Do Not resuscitate) order. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure therapy services were provided as ordered for 1 of 2 (R96) residents reviewed for limited range of motion in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow registered dietician recommendations to prevent weight loss for one (R75) of three residents reviewed for nutrition in the sample of 34.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the (state agency) survey inspection book contained three years of previous survey results for complaint and certification inspections and ensure the survey book was readily accessible to residents and families without asking for assistance to view. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect a vulnerable resident (R1) who is known to become agitated with loud noises and too much stimulation, from being a victim of resident-to-resident abuse on 4/7/2024 and 4/11/2024 and failed to maintain the intervention of 15-minute monitoring for (R1). These failures resulted in an Immediate Jeopardy starting 4/7/2024. While the Immediate Jeopardy was removed on 5/2/2024, 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 Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (R1 and R6) of four residents were free from abuse in a sample of eight. These failures resulted in R1 and R6 both going to the hospital after R1 was struck in the head, and R6 getting a bloody nose.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an incident of abuse for one (R6) of four residents reviewed for abuse investigations in a sample of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician ordered Dilantin level for one of two residents (R47) reviewed for hospitalizations in the sample of 30. This failure resulted in R47 being hospitalized with a critically high Dilantin level.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from verbal abuse for one of one resident (R81) reviewed for abuse in the sample of 30.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure all medication was stored and labeled in accordance with facility policy and procedure, for three of 15 residents (R26, R32, R49) observed for medication pass, in a sample of 30.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a glucose monitor was disinfected between use for two of four residents (R80, R84) reviewed during the medication pass with blood glucose monitoring, in a sample of 30.