Sharon Lane Health and Rehabilitation

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents, with two residents reviewed for accidents and/or hazards. Based on observation, interview, and record review, the facility failed to ensure rooms containing hazardous materials were kept locked and kept them out of reach of the eight cognitively impaired /independently mobile residents. Findings Included: - On 09/29/25 at 07:04 AM, an initial walkthrough of the facility was completed. An inspection of the 200 Hall revealed an unsecured Telephone room with empty boxes and a wire panel that was unlocked. An inspection of the R14's room revealed an uncontained oxygen cylinder sitting directly on the floor. On 09/29/25 at 07:17 AM, Housekeeper Staff U stated the room should be locked. He stated there had been folks at the facility working on the phone lines. Housekeeping Staff U locked the Telephone room. [...]

Inspectors wroteThe facility identified a census of 47 residents. The facility had three medication rooms. Based on observation, interview, and record review, the facility failed to, in accordance with state and federal guidelines, ensure that a vial of tuberculin (a substance used in the tuberculin skin test to detect an immune system response to the bacteria that causes tuberculosis) was labeled properly after being opened.

Inspectors wroteThe facility identified a census of 47 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 19's ventilator mask was stored in a sanitary manner, failed to implement adequate hand hygiene, and further failed to ensure R59's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) was not on the floor.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents, with one sampled resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to preserve Resident (R) 59's dignity when staff failed to ensure that R59's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag was covered with a catheter dignity bag (a bag that conceals urinary drainage bags from public view).

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for self-administration of medication. Based on observation, interviews, and record review, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 43.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for tube feeding complications. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 33's water for tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) bag was marked with the date, time, and the facility further failed to ensure R33's syringe was marked with a date. [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 19's continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored in a sanitary manner.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure dosing instructions for Voltaren (an anti-inflammatory class of medication used to reduce inflammation and treat pain) gel for Resident (R) 31.

Inspectors wroteThe facility had a census of 54 residents. The sample included 14 residents with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 33 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. The facility additionally failed to appropriately transfer Resident (R)4 with two staff resulting in a non-injury fall. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 01/29/24 at 07:15 AM a walkthrough of the facility's Wizard's Way hallway revealed an unlocked oxygen storage closet. The closet contained 15 fully pressurized supplemental oxygen tanks stored in a floor rack and one cylindrical container on a portable stand. [...]

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 34's bilateral lower extremities to prevent pressure ulcers and further failed to monitor refusals to evaluate the ongoing necessity and effectiveness of interventions. This placed R34 at increased risk for pressure ulcer development.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently monitor and document Resident (R) 48's central venous catheter (central line- a catheter placed in a large vein) for signs of infection, bleeding, and other complications. This deficient practice placed R48 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to follow Resident (R)2's physician's orders to notify the medical provider of weight gain related to his diuretic medication (promotes the formation and excretion of urine). These deficient practices placed the resident at risk for unnecessary medications and side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with three residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to prevent a significant medication error when Resident (R) 4 continued to receive an anticoagulant (class of medications used to prevent the formation of blood clots) and mood stabilizer after the medications were discontinued. This deficient practice placed R4 at risk for increased complications and adverse side effects related to medication interaction.

Inspectors wroteThe facility identified a census of 53 residents. The sample included 15 residents with 10 residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure that bathing was provided for one resident who required partial or complete assistance from staff for bathing. This deficient practice placed resident (R)50 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices and impaired psychosocial well-being.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 15 residents, with two residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff implemented interventions per the plan of care for Resident (R) 52. This deficient practice placed R52 at risk for major injuries related to falls.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 15 residents with four reviewed for incontinence care. Based on observation, record review, and interviews, the facility failed to implement incontinence care interventions for Residents (R) 37 and R204. This deficient practice placed the residents at risk for complications related to and increased incontinence. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R37: [...]