Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sharon Health Care Elms during CMS and state inspections, most recent first.
A resident was observed in the morning with dried blood on the lip and teeth, pain with opening the mouth that prevented medication administration, and multiple bruises to the face, head, neck, shoulders, chest, hands, and clavicle. Nursing staff applied ice and notified the DON, but there was a delay of several hours before the resident was sent to the hospital for evaluation of facial and clavicle trauma, despite a facility policy requiring prompt physician notification and action for accidents, incidents, or injuries of unknown origin.
A resident who was totally dependent for transfers and required two or more staff assistance was transferred using a portable lift by a single CNA, contrary to facility policy requiring two-person assistance for lift use. Video showed the CNA entering the resident’s room alone with the lift, closing and later slamming the door, and only later returning with additional CNAs, while other staff sat nearby and did not assist. Shortly afterward, the resident was observed in a wheelchair with a new red area on the left cheek. Nursing, EMS, and hospital documentation described extensive fresh bruising and trauma to the resident’s face, head, neck, shoulders, chest, arms, hands, and lips, with pain on movement of the face and neck and difficulty taking medications, and the DON and physician stated the injuries were consistent with a fall or impact involving the lift.
A cognitively impaired resident with hospital instructions for soft-to-digest foods, 1:1 feeding assistance, and aspiration precautions was incorrectly entered in the system with a general diet, while dietary staff were told the resident required a mechanical soft diet. The care plan and MDS did not identify aspiration risk, did not document a mechanical soft diet, and did not address the need for supervision during meals or the resident’s non-compliance with diet restrictions. Nursing staff did not educate the family about diet restrictions, even though the family routinely brought fast food and snacks, and a CNA reported the resident kept regular-texture snacks in the room. On the day of the incident, a family member brought a roast beef sandwich, which a nurse helped carry to the room and observed being prepared without intervening; the resident, known to eat quickly, choked while eating the sandwich, was found cyanotic and unresponsive with his mouth full of food, and resuscitation efforts were unsuccessful.
Surveyors found that the facility failed to properly label and store medications, including controlled substances. On multiple medication carts, several opened multi-use medications such as insulin vials and levetiracetam liquid lacked documented open dates, and various drugs including insulin glargine, Latanoprost eye drops, Breo and Anoro Ellipta inhalers, and a Basaglar KwikPen were expired but still available for use. In the medication room, an unlocked refrigerator with unlocked drawers contained a controlled substance, lorazepam 0.5 mg IM, that was not secured under double lock as required. Nursing staff and the DON confirmed that these practices did not follow facility policy for dating multi-use medications, discarding expired drugs, and double-locking controlled substances.
A resident with a right lateral foot pressure ulcer that progressed to Stage 4 did not consistently receive ordered wound care or recommended nutritional support. Physician notes documented repeated debridement of necrotic tissue over time, while TARs showed multiple days with no recorded wound treatment despite active orders. An RD twice recommended a liquid protein supplement twice daily for wound healing, but the medical record contained no evidence that these recommendations were implemented. The DON and Administrator confirmed the missing wound care documentation, and the wound physician stated that failure to follow the RD’s recommendations and wound treatment orders would most definitely contribute to the worsening of the wound.
A resident with documented significant weight loss and poor meal intake had repeated RD recommendations for weekly weights to monitor ongoing weight changes, but staff obtained weights only once or twice per month over several months. The RD documented multiple episodes of weight loss and consistently recommended weekly weights, while CNAs and an RN reported they believed only monthly weights were required and were unaware of any weekly weight orders. The RD stated she records her recommendations in dietary notes for nursing to review and obtain MD orders, but these recommendations for weekly weights were not carried out.
Missing Infection Control and Antibiotic Stewardship Logs: The facility failed to maintain Infection Control tracking logs and could not provide a complete list of residents on isolation precautions, including EBP, Contact, or Droplet isolation. The IP and DON stated the required monthly logs for several months were not available, despite the facility policy assigning the IP/Antibiotic Stewardship Leader responsibility for tracking facility infections and monthly lab organism reporting.
A resident's room was not maintained in good repair when the window ledge was observed broken off with sharp edges and exposed wood, and outdoor air could be felt through the opening. The resident, who had a diagnosis of malignant neoplasm of the right lung and no cognitive impairment, stated the problem had been present since admission and caused the room to get cold in winter. The Maintenance Director said he was unaware of the issue and agreed staff should have identified and reported it.
Failure to Obtain Ordered Daily Weights and Notify Physician of Significant Weight Gains A resident with CHF had a physician order for daily weights and for the MD to be notified if weight gain exceeded 3 lbs in a day or 5 lbs in a week. The resident's weight record showed multiple missed daily weights and large weight fluctuations, but there was no documentation that the MD was notified of the significant gains. The Care Plan Coordinator confirmed the weights were not obtained as ordered and were not monitored for discrepancies.
Failure to implement EBP was identified for two residents with wounds, indwelling devices, and other MDRO risk factors. One resident with lymphedema, sepsis, cellulitis, and an acquired wound had no EBP sign, no PPE available, no current EBP order, and was transferred by two CNAs without PPE. Another resident with MS and a G-tube had an EBP order, and culture results showed VRE; however, the DON confirmed the resident was placed on contact isolation without a physician order in the chart.
A resident with severe cognitive impairment and a history of aggressive behavior physically assaulted multiple other residents, causing injuries such as a hematoma, bruising, and pain. Despite documented risks and repeated incidents, staff did not provide adequate supervision or interventions to prevent these episodes of abuse, as confirmed by staff and witness statements and facility records.
A resident who was dependent on staff for transfers and at risk for falls was left unsupervised in an upright reclining wheelchair, contrary to her care plan, resulting in a fall and multiple fractures to her left ankle and foot. The CNA responsible left the resident alone to retrieve linens, and the required intervention to recline the wheelchair was not followed, leading to significant injury and a subsequent hospital visit.
Nursing staff failed to follow proper hand hygiene and glove-changing protocols during wound care for three residents with pressure ulcers, performing wound cleansing and dressing changes without changing gloves or using hand sanitizer as required. Additionally, a scheduled pressure ulcer treatment was missed for a resident, and treatments were not completed as ordered by the physician.
A resident with a history of cerebral palsy and paraplegia fell twice due to staff failing to use a mechanical lift for transfers, as required by the care plan. The first fall occurred during a transfer to a shower chair, and the second fall happened during a transfer from bed to wheelchair, resulting in a femur fracture. The resident expressed fear and distress about future transfers.
A facility failed to assess a resident's mobility, leading to a fall and injury during a transfer. Another resident experienced repeated falls due to ineffective interventions, and a third resident did not receive a required yearly smoking safety assessment, despite cognitive and dexterity issues.
The facility failed to provide bed hold notifications to residents or their representatives during hospital transfers, as required by their policy. Interviews with staff revealed a lack of adherence to the notification process, and the facility administrator confirmed the absence of documentation for the specified dates.
A resident with multiple diagnoses, including Cerebral Palsy and Vascular Dementia, was receiving scheduled pain medication but lacked a care plan for pain management. The facility's policy requires care plans to be initiated within 48 hours of admission and revised as needed. The deficiency was due to a communication issue among care team members, leading to the absence of a pain management plan for the resident.
A facility failed to provide adequate dialysis care for a resident with End Stage Renal Disease. The facility lacked proper documentation, monitoring, and communication with the dialysis center. There was no policy for dialysis care, and the care plan did not specify the dialysis access site or interventions. Additionally, the facility did not have a current contract with the dialysis provider.
Delay in Emergency Evaluation After Resident Found With Extensive Facial and Body Bruising
Penalty
Summary
The deficiency involves the facility’s failure to promptly obtain medical evaluation and treatment for a resident who was found with multiple bruises and facial trauma, despite a policy requiring immediate physician notification and action for accidents, incidents, or injuries of unknown origin. The facility’s change of condition policy states that the nurse will promptly notify the attending or on-call physician when there has been an accident or incident involving the resident, discovery of injuries of unknown source, or a need to transfer the resident to a hospital or treatment center. On the morning in question, the resident was observed by an RN at approximately 8:21 AM with a bruised and swollen left cheek, dried blood on the teeth and left lip, pain with opening the mouth that prevented medication administration, a light bruise on the left clavicle, and a small bruised knot above the left eye; ice was applied to the left cheek. A subsequent nursing assessment at 9:20 AM documented extensive bruising to the right and left anterior shoulders, left lateral head, forehead, left eyelid, left eyebrow, left cheek, left inner ear, left jaw, anterior neck, left upper chest, right dorsal hand, left first knuckle, left medial wrist, and top lip. Despite these findings, the resident remained in the facility for several hours before being sent to the hospital. The RN caring for the resident from 6:00 AM to 6:30 PM stated that around 7:00 AM a CNA asked if she had seen the resident’s cheek, and by about 7:30 AM, when the resident was in the dining room, the RN observed dried blood on the left side of the lip and teeth, and the resident reported pain with opening her mouth and refused crushed medications. The RN also observed a raised bruised left cheek about the size of a quarter, a raised bruise above the left eye about the size of a dime, a knot on the forehead, and a grey bruise on the left clavicle. Although the RN reported notifying the DON, who then spoke with the resident’s physician to obtain an order to send the resident out, the RN acknowledged that the resident was not sent out right away and that there was a delay until around lunchtime. The medical record shows the order to send the resident to the local hospital for evaluation of facial and clavicle trauma at 11:37 AM, and ambulance notes at 11:59 AM document the resident reporting face and neck pain, with hematoma on the forehead, left facial swelling and bruising, dried blood on the teeth, and bruising on the anterior neck, left side, and left clavicle. The hospital record notes that the nursing home had noticed facial bruising, dried blood in the mouth, and pain with movement in the face and neck.
Failure to Follow Two-Person Lift Policy Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies for fall reduction and safe use of a portable lifting machine for a resident who required extensive assistance and total dependence for transfers. The facility’s written procedure for the portable lift required two staff for all lift transfers, and the resident’s mobility assessment documented that she was not steady, needed extensive assistance with bed mobility, was totally dependent for transfers, and required two or more persons for transfer support. Despite these requirements, a CNA reported that she routinely transferred residents alone with the portable lift because she did not like to ask for help, and specifically acknowledged transferring this resident by herself on the day of the incident. On the morning in question, video footage showed the CNA wheeling the portable lift into the resident’s room, closing the door, and later slamming it shut, with no other staff entering the room during the initial transfer period. After several minutes, the CNA moved the lift into the doorway and left the room, then returned with two other CNAs, and shortly thereafter the resident was seen being pushed down the hallway in a manual wheelchair with a visible red area on the left cheek. Other staff were observed on video sitting outside the room on their phones and not assisting during the time the CNA was alone with the lift. The DON and Medical Director later stated that the resident’s injuries were consistent with a fall, and the wound nurse stated that it appeared the resident fell or hit her face/body into the lift frame. Following this sequence, multiple nursing notes, ambulance documentation, and hospital records described extensive fresh bruising and trauma to the resident’s face, head, neck, shoulders, chest, arms, hands, and lips, along with pain with movement of the face and neck and difficulty opening the mouth to take medications. The resident was noted to have dried blood on the lip and teeth, a large laceration inside the mouth, hematomas on the forehead and cheek, and bruising in various locations, including patterns consistent with thumb/finger pressure on the right forearm. The DON, wound nurse, and hospital staff all documented the extent and distribution of the bruising, and the resident was transferred to the hospital for evaluation of facial and clavicle trauma and pain with movement of the face and neck. These events occurred in the context of the resident being described as solid in body and weight, requiring multiple staff to transfer her safely when assessed after the incident.
Failure to Enforce Diet Orders and Visitor Food Policy Resulting in Fatal Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and dietary management to prevent a choking incident for a cognitively impaired resident. The facility had a policy requiring visitors to notify nursing staff before providing outside food so staff could confirm consistency with the resident’s prescribed diet, allergies, and swallowing precautions. Despite this, the resident’s family member reported bringing food, including roast beef sandwiches and soda, to the resident weekly, and stated that staff were aware of this practice and never informed her that it conflicted with the resident’s diet. On the day of the choking event, the family member brought a roast beef sandwich from a fast-food restaurant, and an unknown nurse assisted her in carrying the food to the resident’s room, observed her placing sauce on the sandwich, and told the resident she would return, without addressing diet restrictions or stopping the food from being given. The resident had been admitted with hospital discharge instructions specifying soft-to-digest foods, one-on-one feeding assistance, and aspiration precautions. However, the physician orders entered on admission documented a general diet with regular texture and consistency, and this order was never changed through the date of the resident’s death. The Director of Nursing later acknowledged that the resident was actually on a mechanical soft diet and that the diet order had been entered incorrectly on admission. The Dietary Manager stated that she had been informed the resident was on a mechanical soft diet and that the resident was served as such, but verified that the physician orders and care plan did not match what the resident was being served. The MDS and care plan from admission through death did not identify the resident as an aspiration risk, did not document a mechanical soft diet, did not indicate a need for staff observation while eating, and did not address the resident’s non-compliance with dietary restrictions or any education provided to the resident or family. Nursing documentation from admission through the date of death contained no evidence that staff educated the family about the resident’s dietary needs, including permitted or prohibited foods related to swallowing precautions. Staff interviews confirmed that the family frequently brought snacks and fast food, and that the resident was known to eat and drink very quickly. A CNA reported that the resident had a bin of snacks in the room, including pretzels, prepackaged pastries, crackers, and soda, despite being on a mechanical soft diet. On the day of the incident, staff responded to a CNA’s call that the resident was choking and found the resident cyanotic, unresponsive, and with his mouth full of food. Staff attempted the Heimlich maneuver, performed repeated mouth checks, and initiated CPR until EMS arrived, but were unable to clear the airway. The family member present stated she knew the resident was on a mechanical soft diet but had not been told by staff that the roast beef sandwich conflicted with the resident’s diet, and also stated the resident had garbled speech and confusion and would not have been able to understand or communicate dietary restrictions. The Care Plan Coordinator/MDS nurse stated she relied solely on the diet order in the computer and did not review the hospital discharge instructions, and she never spoke with the family about the resident’s diet. The Director of Nursing stated she never spoke with the family during the resident’s stay and was unaware that the aspiration risk and diet were not included in the care plan. These combined failures in accurately entering and reconciling diet orders, care planning for aspiration risk and supervision needs, enforcing the policy on food brought in by visitors, and educating the family about diet restrictions led to the resident being provided with food inconsistent with the prescribed mechanical soft diet and to the choking event that occurred while the resident was eating the roast beef sandwich brought in by the family member.
Removal Plan
- Initiated daily nursing huddles to review resident diets and identify residents requiring one-on-one supervision during meals.
- Notified all resident families of the facility policy on visitors bringing in outside food and each resident’s diet restrictions.
- Completed an audit of all residents’ diet orders by the Director of Nursing and Dietary Manager.
- Reviewed and verified all resident dietary cards by the Dietary Manager and Director of Nursing.
- In-serviced front desk personnel on handling delivered/outside food: stop family/delivery, notify nurse in charge, and nurse reviews food for consistency with diet orders/restrictions.
- Interdisciplinary Team reviewed and modified the policy on food brought in by visitors to address the new review process.
- Conducted mandatory all-staff training on the revised policy for food brought in by visitors and resident diets/restrictions; all staff in-serviced before start of next shift.
- Mailed a copy of the revised policy on food brought in by visitors to all resident responsible parties/families.
- Added the revised policy on food brought in by visitors to the new admission packet.
Improper Medication Labeling, Expired Drugs, and Inadequate Security for Controlled Substances
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications, including controlled substances, based on observations of medication carts and a medication room, as well as staff interviews and policy review. The facility’s policies required that no discontinued, outdated, or deteriorated drugs be retained for use, that all multi-use medications be properly labeled and legible, and that all controlled substances be stored under double lock and key. Despite these policies, one medication cart contained multiple opened insulin vials and a bottle of levetiracetam liquid without documented dates of opening for several residents, and multiple expired medications including insulin glargine, Latanoprost ophthalmic solution, Breo Ellipta inhalers, Anoro Ellipta inhalers, and a Basaglar KwikPen. Nursing staff confirmed that these medications were either missing required open dates or were expired and should have been discarded. In addition, surveyors observed that the medication room contained an unlocked refrigerator with drawers designated for controlled substances, and those drawers were not locked. A lorazepam 0.5 mg IM (Schedule IV) medication for one resident was found stored in an unlocked drawer, contrary to the facility’s policy requiring all controlled substances to be stored under double lock and key. Registered nurses and the Director of Nursing acknowledged during interviews that multi-use medications must be labeled with the date opened, expired medications must be discarded appropriately, and controlled substances must be double locked, confirming that the observed conditions did not comply with facility policy and accepted standards for medication storage and labeling.
Failure to Follow Wound Care Orders and Implement Nutritional Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered wound treatments and to implement Registered Dietician (RD) recommendations for wound healing for one resident with a pressure ulcer. The facility’s policies require prompt implementation of physician orders and nutritional interventions, including adequate protein, calories, fluids, and supplements for residents at risk of or with pressure ulcers. The resident had a right lateral foot pressure wound that progressed from Stage 3 to Stage 4, with multiple wound physician notes documenting ongoing nonviable tissue, necrosis, and repeated surgical excision of devitalized subcutaneous and muscle-level tissue over several weeks. Treatment Administration Records (TARs) for March and April showed missing documentation of the ordered wound care on multiple specific days, and the DON and Administrator confirmed there was no documentation that wound care was performed on those dates, acknowledging that if it was not documented, it was not done. The RD documented recommendations on two occasions for the resident to receive 30 ml liquid protein twice daily for 30 days to support wound healing. The resident’s current medical record contained no documentation that the facility addressed or implemented these RD recommendations on either date. Despite the ongoing severity of the Stage 4 pressure wound and repeated debridements, there was no evidence in the record that the recommended protein supplement was initiated. The wound physician stated that not following the RD’s recommendation for liquid protein and not following the physician-ordered wound treatments would most definitely contribute to the worsening of the resident’s wounds.
Failure to Implement RD-Recommended Weekly Weights for Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to follow the Registered Dietician’s (RD) recommendations for weekly weights for a resident with documented significant weight loss. The resident’s care plan dated 12/22/2025 notes a significant 6.1% weight loss in one month, with a weight of 153.3 lbs, and further documents that the resident eats about 50% or less of meals and gets up from the table before completing meals. The care plan also notes a 10.7% weight loss over three of six months between December 2024 and March 2025. In response to this weight loss, the RD documented on 1/24/2025 that the resident had lost 10 lbs (6.1%) between 12/16/2024 (163 lbs) and 1/10/2025 (153 lbs) and recommended weekly weights. However, the January weight summary shows only one weight obtained on 1/10/2025. Despite repeated RD notes reinforcing the need for weekly weights due to ongoing weight loss, the facility did not implement these recommendations. On 2/26/2025, the RD documented a weight of 145.8 lbs, a 5% loss from 1/10/2025, and again recommended continuing weekly weights, but the February summary shows only one weight on 2/19/2025. On 3/14/2025, the RD recommended continuing weekly weights for four weeks, yet the March summary shows only two weights (3/13/2025 and 3/21/2025). On 4/3/2025, the RD again recommended weekly weights for four weeks, but the April summary shows only one weight on 4/5/2025. During interviews, two CNAs stated they believed the resident was only on monthly weights and were not aware of any weekly weight order, and an RN confirmed weekly weights were not performed because she was not aware they were needed. The RD stated she documents her recommendations in dietary notes and expects nursing staff to review these notes and obtain orders from the physician, confirming that weekly weights were recommended due to the resident’s significant weight loss.
Missing Infection Control and Antibiotic Stewardship Logs
Penalty
Summary
The facility failed to maintain an Infection Control log for June, July, August, and September 2025. The Resident Roster dated 9/16/25, provided by the Administrator, documented 69 residents in the facility at the time of survey. The facility's undated Infection Control Protocol and Antibiotic Stewardship policy stated that the Infection Control Preventionist/Antibiotic Stewardship Leader would track all facility infections and monthly laboratory organism reporting. On 9/18/25, the Infection Preventionist and DON could not provide a complete list of residents currently on isolation precautions, including Enhanced Barrier Precaution, Contact, or Droplet isolation, or an Infection Control Log for June, July, August, or September 2025. The Infection Preventionist stated on 9/16/25 that she was the facility's Infection Preventionist and produced a certificate of completion for Infection Prevention Program Training dated 2023. On 9/17/25, she stated she did not have Infection Control and tracking logs for the months of June, July, August, or September 2025 and acknowledged that the monthly tracking logs should have been completed in accordance with the Infection Control and Prevention Protocol and the Infection Preventionist's role.
Broken Window Ledge in Resident Room
Penalty
Summary
The facility failed to maintain one resident's room in good repair during the initial tour, specifically R23's room. R23 was admitted with a diagnosis of malignant neoplasm of the right lung, and her MDS documented a BIMS score of 14 with no cognitive impairments. During observation on 9/16/25, R23's window ledge was broken off, had sharp hard edges, and exposed wood, and heat from outdoors could be felt through the broken area. R23 stated she could feel wind coming through the window and that the ledge had been broken since admission about nine months earlier, causing her room to get cold in the wintertime. On 9/18/25, the Maintenance Director stated he was unaware of the broken window ledge and agreed that housekeeping, nursing staff, or any employee providing care should have identified and reported it.
Failure to Obtain Ordered Daily Weights and Notify Physician of Significant Weight Gains
Penalty
Summary
The facility failed to ensure weights were obtained and the physician was notified of weight gains per physician order, and also failed to monitor weights for discrepancies for one of three residents reviewed. The resident had a physician order dated 2/27/25 to be weighed daily due to a diagnosis of congestive heart failure and to notify the physician if the resident gained more than 3 lbs in a day or 5 lbs in a week. The resident's weight summary from 6/1/25 to 9/17/25 showed no documentation of daily weights for 28 of 59 days during 6/1/25 through 9/15/25, and also showed daily weight gain fluctuations ranging from 13.6 lbs to 36.9 lbs. The resident's medical record contained no documentation that the physician was notified of weight gains greater than 3 lbs in a day or 5 lbs in a week. On 9/18/25 at 2:40 PM, the Care Plan Coordinator confirmed the daily weights were not obtained as ordered, the physician was not notified of the gains, and the weights were not monitored for discrepancies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate Enhanced Barrier Precautions for two residents who had conditions placing them at increased risk for MDRO acquisition. One resident was admitted with encephalopathy, lymphedema, sepsis, cellulitis of the right lower limb, protein-calorie malnutrition, and failure to thrive, and the care plan documented impaired skin integrity of both legs related to lymphedema. Hospital records showed the resident had been hospitalized for right lower leg cellulitis resulting in sepsis, treated with IV antibiotics, and later had an acquired pubic wound with ordered dressing changes. During the survey, there was no Enhanced Barrier Precaution sign posted on the door and no PPE available, and two CNAs transferred the resident with a mechanical lift without donning PPE. The record also lacked a current EBP order, and the EBP log did not indicate the resident was on EBP. A second resident was admitted with multiple sclerosis, a gastrostomy, heart failure, and endocarditis, and had physician orders for Enhanced Barrier Precautions. During observation, an LPN performed hand hygiene and applied gloves, assessed and flushed the feeding tube, confirmed the resident was on EBP, and then put on a gown to finish care. Later, the DON provided urine culture results showing a positive vancomycin screen, identified as VRE, and stated the resident was placed on contact isolation even though it was only two more days. The DON also confirmed there was no physician order in the chart for contact isolation at that time.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to adequately supervise a resident with a known history of physical and verbal aggression, resulting in multiple incidents of resident-to-resident physical abuse. The resident in question had documented diagnoses including schizoaffective disorder, psychotic disorder with delusions, and severe cognitive impairment, and was noted in care plans and assessments to display daily physical and verbal behaviors directed toward others, as well as poor impulse control and a history of harm to others. Despite these documented risks, the resident was able to physically assault several other residents on multiple occasions. Specific incidents included the aggressive resident punching another resident in the left eye, causing a hematoma and bruising, and striking another resident in the right arm, resulting in pain lasting several days. Additional documented altercations involved the aggressive resident kicking, scratching, and hitting other residents, some of whom were severely cognitively impaired, non-verbal, or dependent on staff for activities of daily living. Staff and witness statements confirmed that these assaults occurred in common areas such as the dining room and that the aggressive resident's behavior was unpredictable and dangerous to both staff and other residents. The facility's own Abuse Prevention Program policy affirms the right of residents to be free from abuse and outlines the responsibility to prevent mistreatment and identify patterns of potential abuse. However, the repeated incidents involving the same aggressive resident demonstrate a failure to implement adequate supervision and interventions to protect vulnerable residents from physical abuse, as required by facility policy and regulatory standards.
Failure to Supervise and Implement Fall Prevention Measures Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure the safety of a resident who was dependent on staff for all activities of daily living except eating and was at risk for falls due to multiple diagnoses, including dementia, vertigo, Alzheimer's disease, and muscle weakness. The resident was transferred to her room in a reclining wheelchair by a CNA, who then left the room to retrieve bed linens, leaving the resident unsupervised. During this time, the resident fell from the upright reclining wheelchair, which was not reclined as required by her care plan intervention, resulting in her landing on the floor with the chair tipped forward. The resident's care plan specifically required that the reclining wheelchair be in the reclined position when the resident was seated and not eating, an intervention that was not followed at the time of the incident. The CNA later acknowledged that reclining the chair could have prevented the fall. The resident sustained significant injuries, including pain, swelling, and bruising to her left foot and ankle, which were not immediately recognized as fractures. The incident was unobserved, and the resident was found on the floor by staff upon their return. Subsequent documentation and interviews confirmed that the resident experienced increasing pain and swelling in the days following the fall. Medical evaluation revealed multiple fractures in the left ankle and foot, necessitating a hospital visit and further orthopedic care. The failure to provide adequate supervision and to implement the required safety intervention directly contributed to the resident's fall and resulting injuries.
Failure to Follow Hand Hygiene and Treatment Orders During Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during pressure ulcer treatments for three residents with documented wounds. Observations revealed that the wound care nurse performed wound cleansing and dressing changes without changing gloves between dirty and clean tasks, and did not use hand sanitizer or wash hands between glove changes or between residents. In several instances, the nurse removed soiled dressings, cleansed wounds, and applied new dressings all while wearing the same pair of gloves, and only used hand sanitizer after leaving the resident's room, without performing handwashing as required by facility policy. Additionally, the facility did not ensure that pressure ulcer treatments were completed as ordered by the physician. For one resident, the treatment administration record showed that a scheduled dressing change was missed, and the Director of Nursing confirmed that the treatment was not completed as ordered. The nurse involved stated that she did not always use hand sanitizer between glove changes if her hands appeared clean and admitted to not following the correct procedure during the observed wound care sessions. Facility policies for wound care, glove use, handwashing, and physician order implementation require hand hygiene before and after procedures, glove changes between tasks, and completion of treatments as ordered. These requirements were not followed during the observed wound care sessions, resulting in a failure to provide appropriate pressure ulcer care and to prevent the potential for new ulcers or infections.
Failure to Use Mechanical Lift Results in Resident Falls
Penalty
Summary
The facility failed to transfer a resident using the required mechanical lift, resulting in two falls for the resident. The resident, who has a history of cerebral palsy, left hip fracture, and left-sided paraplegia, was supposed to be transferred with extensive assistance by two staff members using a mechanical lift. However, on two separate occasions, staff members attempted to transfer the resident without the mechanical lift, leading to falls. The first incident occurred when a CNA attempted to transfer the resident from a wheelchair to a shower chair without using the mechanical lift. The resident turned suddenly, thinking her phone had fallen, and fell onto her buttocks. The CNA was not aware that the resident required a mechanical lift for transfers. The second incident involved another CNA who attempted to transfer the resident from the bed to a wheelchair without the mechanical lift, resulting in the resident's leg buckling and the CNA lowering the resident to the floor. This incident led to a periprosthetic distal left femur fracture and ongoing pain for the resident. The resident expressed fear and distress about being transferred with a mechanical lift following these incidents. The facility's policy and the resident's care plan clearly indicated the need for a mechanical lift and two staff members for all transfers, but this was not adhered to by the staff involved. The failure to follow the care plan and facility policy directly contributed to the resident's falls and subsequent injury.
Deficiencies in Resident Assessment and Safety Measures
Penalty
Summary
The facility failed to conduct a proper assessment of a resident's mobility and physical impairment, which led to an inappropriate transfer method being used. This resulted in a resident, identified as R9, experiencing a fall while being transferred using a mechanical stand lift. The staff involved did not ensure the bed was in the correct position due to a lack of electricity in the room, which was not addressed promptly. Consequently, R9 fell to the floor, sustaining a coccyx fracture and severe pain, requiring hospitalization. Another deficiency was noted in the facility's failure to implement effective fall interventions for a resident, identified as R8, who had a history of falls. Despite multiple incidents of R8 sliding out of the wheelchair and falling, the interventions put in place, such as a gripper pad, were ineffective as R8 frequently removed it. The facility did not reassess or implement alternative strategies to prevent further falls, despite R8's impaired decision-making and memory. Additionally, the facility did not conduct a yearly smoking safety assessment for a resident, identified as R40, who was an independent smoker. The resident had cognitive and dexterity issues, yet there was no staff supervision while smoking, and the last assessment was conducted over a year ago. This oversight was contrary to the facility's policy, which mandates annual assessments to ensure residents' safety while smoking.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notifications to residents or their representatives during hospital transfers, as required by their policy. The policy mandates that all residents receive a notification of the bed reserve policy upon admission and again upon hospitalization. However, for four residents reviewed, there was no evidence of such notifications being provided during multiple hospital transfers. Specifically, residents were transferred to hospitals on various dates, but their medical records lacked documentation of bed hold notifications. Interviews with facility staff revealed a lack of adherence to the bed hold notification process. The Minimum Data Set Nurse acknowledged that floor nurses were responsible for providing these notifications but could not find documentation for the residents in question. The facility administrator also confirmed the absence of documentation for the specified dates and admitted that there was no consistent routine for issuing these notifications. This deficiency was identified during a survey conducted by the surveyors.
Failure to Develop Pain Management Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for pain management for one resident, identified as R4, among 24 residents reviewed for pain management. According to the facility's Care Plan Policy dated June 1, 2023, a care plan should be initiated within 48 hours of admission and completed no later than 21 days after admission. Care plans are to be revised quarterly or as needed based on changes in the resident's condition. R4 was admitted with multiple diagnoses, including Cerebral Palsy, Muscle Wasting and Atrophy, and Vascular Dementia. Despite having a physician's order for Acetaminophen with Codeine for pain management, R4's care plan did not include a plan for addressing pain. The deficiency was identified through interviews and record reviews. On October 8, 2024, the Minimum Data Set/Care Plan Coordinator, identified as V4, confirmed that R4 did not have a care plan for pain. The Director of Nursing, identified as V2, acknowledged that R4 had been receiving scheduled pain medication for about a month for lower back and general body pain, yet a care plan for pain was not developed. The lack of communication between care team members was cited as the reason for the oversight in developing a pain management care plan for R4.
Inadequate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident requiring such services. The resident, who was admitted with diagnoses including End Stage Renal Disease, did not have proper documentation or monitoring of their dialysis access site. The facility lacked a policy and procedure for the care of dialysis residents, and there was no communication with the dialysis center regarding the resident's care. The resident's care plan did not specify the location of the dialysis access device or detail specific complications or interventions, and there was no documentation of monitoring the dialysis access device in the resident's medical records. Additionally, the facility did not have a current or valid dialysis contract with the company providing dialysis services to the resident. The administrator acknowledged the absence of necessary communication with the dialysis provider and the lack of a valid contract or policy for caring for a dialysis resident. The facility's failure to maintain proper documentation and communication, as well as the absence of a current dialysis contract, contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sharon Health Care Willows | 0 mi | ★★★★★ | 5 | 0 |
| Sharon Health Care Pines | 0.1 mi | ★★★★★ | 16 | 1 |
| Loft Rehab Of Peoria, The | 2.6 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Skylines | 2.6 mi | ★★★★★ | 0 | 0 |
| Accolade Healthcare Of Peoria | 3.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.