Sharpview Residence and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1medication cart (200 Hall Nurse Cart) reviewed for pharmacy services . LVN A failed to ensure the 200 Hall Medication Nursing Cart was locked when not under direct supervision of authorized staff ON 5/27/26 at 10:26 AM. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (CR #1) of 4 residents reviewed for tracheostomy care.-LVN A failed to provide emergency tracheostomy (surgical hole in the windpipe to assist with breathing when the usual way is blocked) reinsertion for CR #1 after the resident accidentally removed their tracheostomy on 04/27/2025. LVN A did not use an obturator (an instrument used to guide the cannula (tubing that allows oxygen to go through the windpipe) back into a resident's opening (the surgical hole in the windpipe also called a stoma) during reinsertion) and did not know what it was or how to use an obturator. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 3 residents (Resident #8) reviewed for coordination of PASARR and assessments. -The facility failed to conduct the PASARR Level I assessment Form 1012-Mental Illness/Dementia Resident Review for Resident #8 until 7/24/25.-The facility failed to request, submit and coordinate the PASARR assessment and screening in the Simple LTC portal to ensure therapeutic services (physical, speech and occupational) were completed for Resident #8. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the resident's comprehensive assessment for 1 (Resident #9) of 5 residents reviewed for quality of care. -Resident #9 was found with a skin tear on 07/24/2025 after surveyor intervention . LVN B, CNA G and CNA V cared for Resident #9 and did not document the skin tear prior to 07/24/2025. This failure could lead to residents not receiving timely wound interventions and could cause further wound deterioration, infection and decline in health. Record review of Resident #9's face sheet dated 07/26/2025 revealed a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE] . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including adminstering drugs and biologicals to meet the needs for each resident for 1 (Resident #105) of 4 residents reviewed for medication administration. LVN F did not correctly check Resident #105's g-tube placement before medication administration. LVN F did not stir the medications before administering it through the g-tube. LVN F left a substantial amount of medication residue in the medication cups after Allopurinol 100 mg give 0.5 tablet and Amoxicillin-Pot Clavulanate tablet 500-125 mg were administered through a g - tube to Resident #105. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6%, based on 2 errors out of 31 opportunities, which involved 1 (Resident #105) of 4 residents reviewed for medication errors. - LVN F left a substantial amount of medication residue in the medication cups after Allopurinol 100 mg give 0.5 tablet and Amoxicillin-Pot Clavulanate tablet 500-125 mg were administered through a g - tube to Resident #105.- LVN F did not stir the medications before administering it through the g-tube. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 4 residents (Resident #25) reviewed for significant medication errors.- LVN S failed to administer medication as ordered to Resident # 25 when she injected insulin Lispro 5 units subcutaneously (below the top skin layer) and all the insulin was not administered to the resident. This failure could place residents at risk of hyperglycemia, and potential hospitalization. Record review of Resident #25's face sheet dated 07/24/25 revealed a 51year old male was initially admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included: diabetes mellitus with hyperglycemia (persistently high blood sugar), dysphagia (difficulty swallowing), and metabolic encephalopathy (brain dysfunction due to chemical imbalance in the body). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 (Freezer A) of 1 freezer observed for food storage.-There were 3 packets of onion soup base which had best used by dates of 07/11/2025 in Freezer A. This failure could put residents at risk of food contamination and illness due to being served food past the best used by date. Observation of Freezer A on 7/22/2025 at 8:25am, revealed there were 3 5.4 oz. packets of onion base soup powder dated best if used by 07/11/2025 and labelled 11-12 in black ink pen. During observation and interview with the Dietary Manager on 7/22/2025 at 8:25am, the Dietary Manager said those packets should be thrown away and that everyone in the kitchen was responsible for checking for dates. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Hall A) of 3 halls observed for infection control.-There was a trash bag with white and blue linen left outside Resident #12's room by the doorway on the floor. This failure could place residents at risk of contagious diseases and spread of illness when infection control protocols are not followed. Observation and interview in Hall A on 7/23/2025 at 3:40pm, revealed there was a trash bag on the floor outside Resident #12'sroom. The bag was tied up and contained white and blue linen. MA V saw the bag and took it and walked it down the hall to the trash room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for oxygen therapy for two of two residents (Resident # 29 and Resident #186) reviewed for respiratory care. -The facility failed to follow the physician orders for Resident #29's oxygen administration. -The facility failed to provide tracheal care and suctioning according to professional standards for Resident #186. These deficient practices could result in the resident's not receiving the care and services ordered by the physician and a decline in health status and oxygen deprivation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 9% based on 3 errors out of 32 opportunities, which involved 3 of 9 residents (Resident #29, Resident #14 and Resident #6) reviewed for medication errors. 1. RN A did not administer Sodium Chloride (a prescription medicine used to replenish lost water and salt in your body due to certain conditions like low salt syndrome) to Resident #29 as ordered by the physician. 2. MA A did not administer Losartan Potassium ( a drug used to lower blood pressure) to Resident #14 as ordered by the Physician. 3. RN B did not administer Valproic Acid ( a drug works by lowering seizures) to Resident #6 as ordered by the physician. [...]

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were labeled and dated. 3. The Facility failed to ensure food was stored in designated areas at all times. 4. The facility failed to thaw frozen 2-5 lb. rolls of frozen ground beef. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 06/11/24 at 8:15 AM revealed the following. 1. A Plastic Container of Pureed sausage saved from breakfast dated 6/05/24 use by date 06/10/24 2. A Plastic container of Sour cream dated 5/21/24 no use by date 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for five of six residents, (Resident #5, Resident #10, Resident #13, Resident #136 and Resident #186) and three of four staff (LVN A, LVN B, CNA A, RN A) reviewed for infection control and prevention, in that: 1. Resident #186's pressure sore treatment was not done with the clean technique. 2. CNA A did not perform hand hygiene before or after Resident #10 nor Resident #13's incontinence/indwelling catheter care. 3.4. LVN did not follow proper technique in cleaning accu-check machine between Resident #136 and Resident #5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 5 residents (Resident #29) reviewed for laboratory services. The facility did not obtain CBC levels for Resident #29 following orders on 6/6/2024. This failure could place residents at risk of not receiving treatment and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 1 of 4 residents (Resident #1) reviewed for pharmacy services, in that: -The facility failed to ensure Resident #1was monitored during medication administration. This failure could place residents at risk of not receiving their medications, chocking and respiratory distress.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments for one (Nurse Medication Cart [NAME] Hall) of four medication carts observed for storage of medications. The facility failed to ensure the Nurse Medication Cart [NAME] Hall was secured when unattended. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -The facility failed to ensure food items with an expired use by date were removed from the refrigerator. -A food item was not cooled properly before being placed in the walk-in refrigerator and was 100 degrees Fahrenheit when tested with a thermometer. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.