Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Pines during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse when, after an initial confrontation over condiment packets at a breakfast table, staff redirected and separated two residents but allowed them to come into contact again in a hallway. One resident with moderate cognitive impairment and psychiatric diagnoses became agitated after another resident with a history of substance abuse took pepper packets from a tablemate’s tray. Although staff initially intervened, a subsequent encounter occurred in the hallway where the agitated resident stood up, struck the other on the back of the head, grabbed him, and pulled his shirt, resulting in the victim ending up on the floor or knees before staff again separated them. Progress notes documented a physical altercation and that no injuries were noted.
A resident with multiple psychiatric diagnoses, poor safety awareness, and a documented restriction from unsupervised community access was able to call a taxi, exit through the front door, and leave the premises despite staff and security presence, and was returned without any documented assessment, elopement precautions, or 15‑minute checks being initiated or added to the care plan. Multiple CNAs, RNs, and security staff reported they did not know which residents had restricted passes, relied on a front‑desk binder they could not memorize, and were not informed of the elopement, citing poor communication and staffing issues. Two other residents with restricted passes later exited through a side door that had been propped open by an outside vendor, further demonstrating that staff were not consistently preventing unsupervised exits or following the facility’s elopement and pass policies.
The facility failed to provide sufficient licensed nursing staff in accordance with its own staffing policy and staffing calculator, which required specific numbers of nurses and licensed nursing hours on each shift based on census and acuity. Timecard reviews showed that on multiple shifts there were fewer nurses working than required, including shifts with only one nurse on duty where more were indicated. The DON acknowledged ongoing staffing shortages, lack of awareness of the calculator’s required nurse numbers, and reported that nurses complained they could not complete their work. An RN stated she was unable to complete resident charting because the unit was too busy and understaffed, and the DON noted holes in MAR and TAR documentation that nurses attributed to low staffing, affecting care for approximately 110 residents.
The facility did not ensure that an RN was on duty for eight consecutive hours within a 24-hour period as required. Review of nurse timecard reports for a specified timeframe showed no RN coverage for the required continuous eight-hour period on one of the days reviewed, and the DON confirmed that no RN worked that day. At the time, the facility’s CMS LTC application documented that 110 residents were residing in the facility.
Surveyors found multiple failures in food storage, labeling, and kitchen sanitation, including undated and expired food items, thawed pre‑cooked meats and waffles stored without dates, and an opened, undated container of gravy mix powder. A freezer was operating at 42°F with thawed, sealed bologna that had not been discarded, and the unit had not been taken out of service despite the temperature issue. Additionally, heavy black, stringy dust was observed on a ceiling vent and surrounding tiles directly over an uncovered beverage preparation area. The Dietary Manager confirmed these conditions were inconsistent with facility policy and that Maintenance had been aware of the ceiling and vent condition, with these issues having the potential to affect all residents.
The facility failed to implement an effective pest control program for flies despite having a written pest control policy and regular pest control invoices that showed no treatment for flies. Multiple flies were observed in the kitchen near the juice machine, preparation sink, cup storage area, and on the steam table and food-contact surfaces during a meal. A resident in a wheelchair reported flies constantly landing on her while eating, and another resident reported flies swarming an uncovered trash can used for soiled disposable undergarments at the entrance of a hall, which surveyors observed on more than one occasion. The Dietary Manager acknowledged the flies and lack of known preventative measures, and the Administrator confirmed the facility had not been treated by pest control for flies, while 110 residents were documented as residing in the facility.
The facility did not provide mandatory annual Quality Assurance and Performance Improvement (QAPI) training to its staff. Review of in-service records over a one-year period showed no documentation of QAPI training for any staff members, despite the presence of 110 residents in the facility. This was confirmed by an administrative assistant, who stated that no staff had received the required annual QAPI education.
Surveyors identified that nursing staff failed to document medication administration on MARs for multiple residents, despite a facility policy requiring immediate documentation and prohibiting pre‑ or post‑signing. Review of August MARs showed numerous missing entries for ordered medications, including insulin, cardiovascular drugs, psychotropics, inhalers, pain medications, and other chronic therapies, with some medications lacking documentation 5–10 or more times. One resident with Type 2 DM had both mealtime and twice‑daily insulin not recorded as given on multiple days, and an RN who worked that weekend could not explain the lack of documentation. The DON confirmed the missing entries and attributed the problem to inadequate staffing, resulting in a pattern of undocumented medication administration across the residents reviewed.
A resident with psoriasis and excoriation had physician orders for triamcinolone 0.1% cream to affected areas on weekdays and antifungal powder to abdominal folds three times daily, with the care plan reflecting these treatments. Observation showed multiple red, raised, flaky skin lesions and the resident reported worsening psoriasis and eczema. MAR review revealed the triamcinolone cream was never administered after being ordered and the antifungal powder was missed for the majority of scheduled doses, which a RN and the DON confirmed as not given.
Surveyors identified that staff did not follow physician orders and professional standards during medication administration, resulting in a 12% medication error rate. An LPN administered an Albuterol inhaler without shaking it or instructing a resident to rinse and spit as ordered. Another LPN administered fewer units of Insulin Lispro than required by a sliding scale for a resident with an elevated blood glucose. An RN administered Insulin Aspart to a resident using an expired vial and in a total dose that did not align with the ordered regimen and sliding scale.
Surveyors found that staff failed to date opened insulin vials before administering Insulin Lispro per sliding scale to two residents. An LPN drew 18 units from an opened, undated vial for one resident, and an RN drew 2 units from another opened, undated vial for a second resident; both nurses stated they did not know when the vials were first accessed. The DON reported that facility policy requires insulin vials to be dated when first opened and used only for a defined 28-day period before disposal.
A resident with DM had physician orders for twice-daily fingerstick blood glucose monitoring and Insulin Lispro per sliding scale based on pre-meal blood glucose results. Review of the MAR showed multiple missed entries where staff did not document the resident’s fingerstick blood glucose results on several days, despite the standing orders. The DON confirmed the orders and stated that staff were responsible for performing and recording the blood glucose testing so the physician could monitor the resident’s blood sugar levels.
Staff failed to follow the facility’s glucometer cleaning policy requiring disinfection with a disinfecting wipe and a 5-minute dry time after each use. An LPN performed finger-stick blood glucose tests on two residents using the same shared glucometer, cleaning it only with an alcohol pad between uses and immediately returning it to the medication cart. The DON later confirmed that shared glucometers were required to be disinfected with a disinfecting wipe after each use, not an alcohol wipe.
A resident with cognitive impairment was physically pushed by another resident with a history of aggression, resulting in a fall. Facility staff did not notify the administrator or implement interventions after the incident, and an investigation was delayed until the administrator was later informed.
A resident was pushed by another resident, resulting in a fall, but the incident was not reported to the administrator or the State Agency as required by facility policy. Documentation confirmed the altercation, but no investigation or external reporting was completed because the administrator was not notified.
A physical altercation occurred between two residents, resulting in one resident being pushed and falling to the floor. Facility policy requires immediate reporting and investigation of such incidents, but the administrator was not notified, and no investigation or reporting took place.
Two residents with behavioral and psychiatric diagnoses engaged in a verbal and physical altercation on the smoking patio, during which one resident was pushed out of a wheelchair by another, resulting in a complex hip fracture that required surgery. Witnesses confirmed the escalation from verbal conflict to physical abuse, and another resident was also struck during the incident. The facility did not prevent the physical abuse as required by its policies.
A resident sustained a complex left hip fracture after a physical altercation with another resident on the smoking patio. Despite facility procedures requiring law enforcement notification for resident-to-resident physical abuse resulting in injury, the police were not contacted following the incident.
Staff failed to investigate or document an incident where a resident and others were exposed to a toxic chemical in the dining room. Despite symptoms such as coughing and eye irritation, no nursing assessments or incident reports were completed, and the facility could not identify all affected residents or provide required documentation.
A CNA engaged in taunting, derogatory, and threatening behavior toward a resident, including making disparaging remarks and physical gestures, which caused emotional distress and fear. Multiple staff and residents reported a pattern of confrontational and abusive conduct by the CNA, and the facility failed to protect residents by allowing the CNA to return to work after an initial suspension.
A resident with severe cognitive impairment and poor impulse control physically assaulted another resident, resulting in a facial laceration requiring sutures. The incident occurred in the TV area, where both residents were present, and staff intervention was not timely enough to prevent the altercation. The facility's abuse prevention policy failed to protect the resident from this incident.
Two residents with TBI diagnoses were involved in a physical altercation in the dining room, resulting in one resident sustaining a scratch. Despite staff presence, they could not intervene before the incident escalated from a verbal to a physical confrontation. The facility's abuse policy emphasizes prevention, but the incident highlights a failure to protect residents from physical abuse.
The facility did not respond to repeated Resident Council concerns about small meal portions and limited administrative availability, affecting all 96 residents. Despite consistent documentation of these issues in meeting minutes, the Dietary Manager and Administrator failed to address the grievances, contrary to the facility's policy of prompt resolution.
The facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs) among its 96 residents. Despite having a policy for EBP, observations showed no residents in isolation or signs indicating EBP implementation. The Director of Nursing confirmed that EBP had not been implemented, even though two residents had open wounds requiring dressing changes, and only standard precautions were used.
The facility failed to prevent and monitor abuse among residents, resulting in physical altercations. One resident with a history of aggression was involved in two incidents on the smoking patio, despite requiring supervision. Another altercation occurred in the dining room, escalating from a verbal to a physical confrontation. These incidents highlight lapses in adherence to the facility's abuse prevention policy.
A resident, recently hospitalized and with a changed diet order, was treated dismissively by a staff member when addressing a meal discrepancy. The staff member, V10, instructed the resident to speak with their nurse and turned away, leaving the resident upset. V10 perceived the resident as aggressive, though no specific aggressive behavior was noted during the interaction. This incident violated the facility's Resident Dignity policy.
A resident expressed a desire to return to a previous LTC facility, but the current facility failed to assist in the transfer process. Despite the resident's repeated requests and the facility's policy on discharge planning, no attempts were documented to facilitate the transfer, and the previous facility confirmed no requests for rescreening were received.
The facility did not update the PASARR for two residents who were diagnosed with psychiatric conditions after admission. One resident was diagnosed with Schizoaffective Disorder, Bipolar Type, and another with Other Schizoaffective Disorders. The Quality Assurance staff confirmed the absence of updated screenings to determine the need for Level II PASARR.
A resident's chart was not updated to reflect a change from Full Code to Modified DNR, resulting in the resident receiving unwanted CPR, including chest compressions, after being found unresponsive. The POLST indicated no chest compressions, but the care plan was not updated until after the resident's death. The LPN and CNA involved were unaware of the change, leading to EMS performing full resuscitation efforts.
A resident with limited range of motion did not receive ordered therapy services for six weeks, despite having a physician's order for speech, physical, and occupational therapy. The resident and his Power of Attorney had to arrange therapy themselves, as the facility failed to send referrals to the outside therapy department. The Restorative Nurse confirmed the delay in treatment and acknowledged that the resident was not on a formal restorative program to prevent further decline.
A resident experienced significant weight loss over several months due to the facility's failure to implement the registered dietician's dietary recommendations. Despite documented weight decline and specific dietary suggestions, the resident did not receive the necessary supplements, and staff were unaware of any special dietary interventions. The facility's weight policy was not followed, leading to a deficiency in maintaining the resident's nutritional health.
The facility failed to provide residents with easy access to three years of survey results, including complaint and certification inspections. Residents were unaware of where to find these results, and the survey book, located behind the reception desk, contained only the 2023 annual survey. The Quality Assurance representative confirmed the book's limited contents and explained that it was kept in a room that was not always unlocked.
A resident with a history of Traumatic Brain Injury and susceptibility to overstimulation was involved in two physical altercations with other residents due to the facility's failure to maintain required 15-minute checks and provide adequate supervision. The incidents resulted in injuries to the resident, highlighting deficiencies in the facility's abuse prevention measures.
Failure to Prevent Resident-to-Resident Physical Abuse Following Dining Room Altercation
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse, contrary to its Abuse Prevention Program Policy affirming residents’ right to be free from abuse. One resident (R2), admitted with alcohol abuse, diabetes, anxiety disorder, and psychoactive substance abuse and documented as having little or no cognitive impairment (BIMS score 14), was involved in a physical altercation with another resident (R3). R3, who was admitted with obsessive-compulsive disorder, ischemic heart disease, mood disorder with manic features, and encephalopathy and had moderate cognitive impairment (BIMS score 10), became agitated when R2 removed black pepper packets from another resident’s meal tray during breakfast in the dining room. R3 confronted R2 and removed the pepper packets from R2’s possession. Staff intervened at that time, redirected both residents, and separated them. A few minutes after the initial altercation, while R2 was walking past R3 in the C hallway, R3 stood up and struck R2 on the back of the head. Staff accounts differ slightly in detail but consistently describe a second physical incident in the hallway: one CNA reported that R3 jumped up, grabbed R2, hit him, and pulled on his shirt collar, while security staff reported returning from checking the front door to find both residents in the C hallway with R2 on the ground. An RN reported that when assisting to separate the residents, R2 was on his knees in the hallway. Nursing progress notes for both residents on the date of the incident document that they were in a physical altercation, were separated by staff, and that no injuries were noted. The sequence of events shows that after the initial confrontation in the dining room, the residents were able to come into contact again in the hallway, resulting in R3 physically striking and grabbing R2, constituting abuse that the facility failed to prevent.
Failure to Prevent Elopement and Implement Required Safety Measures for Residents With Restricted Passes
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent elopement for multiple residents with restricted community passes. One resident with a history of disorganized and paranoid schizophrenia, bipolar II disorder, delusional disorder, personality disorder, anxiety, poor insight and judgment, scattered thought process, poor decision-making skills, and poor safety awareness had been assessed as not capable of unsupervised outside community passes and did not know the facility address or how to contact someone in an emergency. Despite this, the resident’s care plan did not include safety interventions related to restricted community pass status and did not document the pass restriction. On the day of the incident, the resident independently called a taxi using a personal cell phone, walked out the front door, and entered the taxi while staff and security attempted to stop the departure, and the resident instructed the driver to leave. The resident was later returned by the taxi company, but there was no documented assessment after return, no initiation of elopement precautions, and no 15‑minute checks or other monitoring documented in the medical record. Staff interviews revealed that the nurse who was aware of the elopement did not document the incident, stating that the DON said she would chart it and citing staffing shortages and workload. Security staff reported seeing the resident outside on a cell phone and then entering a taxi, yelling for the resident to stop because there was no pass, and then notifying facility staff after the taxi left. Another security staff member assigned to the front entrance that day, who usually worked in housekeeping, stated he did not know the resident, did not recall any residents leaving, and was unaware the resident had exited while he was on duty. Multiple CNAs and nurses reported they did not know which residents had passes or restricted passes, relied on a binder at the front desk that listed pass status, and stated they could not memorize all residents’ pass restrictions. Several staff members, including CNAs and an RN, stated they were not aware that the resident had eloped, that the information was not passed on to them, and that communication in the facility was poor, with management not informing them of such incidents. Additional deficiencies were identified when two other residents with restricted community passes exited the facility unsupervised through a side door that had been propped open by an outside vendor working on the heating and cooling unit. One resident was observed outside near the main entrance and was escorted back into the facility, while another resident reported following the first resident outside to make sure he did not leave and then yelling for staff. Staff interviews confirmed that both of these residents had restricted passes and were not to leave without staff. The facility’s own elopement and missing person policy required that upon a resident’s return after elopement, staff initiate an assessment, notify family, complete documentation, place the resident on elopement precautions, review sign‑out procedures, and implement monitoring such as 15‑minute checks for at least 24 hours, with IDT reassessment. However, for the resident who left by taxi, these required steps were not implemented or documented, and the resident’s care plan and electronic medical record continued to lack updated safety interventions and monitoring strategies even days after the elopement. The cumulative failures in care planning, staff education on pass status, monitoring, communication, and adherence to the elopement policy resulted in an Immediate Jeopardy determination.
Insufficient Licensed Nursing Staff and Unmet Staffing Calculator Requirements
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to meet residents’ needs and to follow its own staffing policy and staffing calculator requirements. The facility’s Staffing Policy dated 4/30/25 states that minimum numbers of nursing staff must be established and maintained based on census and resident acuity. The facility’s staffing calculator for multiple dates in August 2025 documented that four nurses (32 licensed nursing hours) were required on day shift, three nurses (24 licensed nursing hours) on evening shift, and two nurses (16 licensed nursing hours) on night shift. However, timecard reports for 8/5/25 through 8/24/25 showed that on several dates the actual licensed nursing hours fell below these calculated requirements. For example, on some days only one nurse worked the day shift, one to one-and-a-half nurses worked the evening shift, and one nurse worked the night shift, instead of the higher numbers required by the staffing calculator. The Director of Nursing confirmed multiple staffing shortages on specific dates and stated that staffing is an issue and that she was not aware the staffing calculator required four nurses on days, three on evenings, and two on nights. A registered nurse reported that she did not chart on her residents on one of the cited dates because things were too busy and there was not enough staff. The DON also stated that nurses complain about staffing numbers, report they cannot get things done, and that the MARs and TARs have holes in charting, which nurses attribute to not having enough time due to low staffing. At the time of the survey, the facility’s CMS LTC application documented a census of 110 residents, all of whom had the potential to be affected by these staffing shortages.
Failure to Provide Required RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours in a 24-hour period, as required. During a survey on 8/28/25 at 8:30 AM, the Director of Nursing (V2) provided nurse timecard reports covering 8/5/25 through 8/24/25, which showed no documentation of an RN working eight consecutive hours on 8/12/25. At 10:15 AM the same day, V2 confirmed that there was no RN working on 8/12/25. The facility’s Centers for Medicare & Medicaid Services Long Term Care Application, dated 8/25/25 and signed by the Administrator (V1), documented that 110 residents were residing in the facility at the time.
Improper Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own Labeling and Dating and Food Policy and cleaning practices. During a kitchen tour with the Dietary Manager, an opened five‑pound tub of cottage cheese was found in a three‑door refrigerator, one‑quarter full, undated, and past its printed expiration date. Three gallon‑sized plastic bags of thawed, pre‑cooked chicken and a gallon bag of thawed, pre‑cooked hamburger patties were stored without dates, and two boxes of waffles labeled by the manufacturer to be kept frozen were observed thawed and undated in the refrigerator. On a preparation table next to the stove, a plate containing a piece of ham and two pancakes covered in plastic wrap was undated, and on a dry storage rack, an opened, half‑full 24‑ounce container of gravy mix powder was undated. The Dietary Manager confirmed that these items should have been labeled and dated in accordance with the facility’s policy and that the expired cottage cheese should have been discarded. Additional deficiencies were observed in equipment maintenance and environmental cleanliness in the kitchen. In the kitchen freezer, the thermometer registered 42°F, and the Dietary Manager stated the unit had failed that morning and that maintenance had been notified, further acknowledging that the freezer should have been taken out of service and that three sealed, undated packages of bologna found thawed in the freezer should have been discarded. During drink preparation, surveyors observed a heavy accumulation of black, stringy dust hanging from a ceiling vent and surrounding tiles directly over an uncovered prepared beverage area. The Dietary Manager verified the presence of the black dust on the ceiling vent and tiles and stated that Maintenance was responsible for cleaning the kitchen ceiling and vents and had been aware of the condition. The facility’s CMS LTC application documented that 110 residents resided in the facility at the time of the survey.
Failure to Implement Effective Pest Control for Flies in Resident and Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its Pest Control Policy dated 4/25/25, which calls for prevention, sanitation, and integrated pest management across all buildings and grounds. Pest control invoices for March through August 2025 did not show any evidence that the facility was being treated for flies. During a kitchen tour, multiple flies were observed near the juice machine, preparation sink, and cup storage area. The Dietary Manager acknowledged the presence of flies, attributed them to frequent opening of the dining room door, and stated she was unaware of any pest control measures being used to keep flies out of the kitchen. A resident in a wheelchair reported that flies constantly landed on her while she ate in the dining room, and during the interview two flies were observed landing on her arm, which she swatted away. Another resident reported that a trash can without a lid at the beginning of C-Hall, used for disposal of soiled disposable undergarments, was constantly swarmed by flies and described them as very annoying. Surveyors observed this uncovered trash can filled with soiled undergarments at the entrance of C-Hall with a swarm of flies, and later again observed the same trash can filled with soiled undergarments with multiple flies present. During a noon meal, a fly infestation was observed in the kitchen, with flies landing on the steam table and food-contact surfaces. The Administrator confirmed the facility had not been treated by a pest control service for flies. The facility’s CMS LTC application documented that 110 residents resided in the facility at the time of the survey.
Lack of Annual QAPI Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory annual training on the facility’s Quality Assurance and Performance Improvement (QAPI) program. Review of the facility’s CMS Long Term Care Application, dated 8/25/25 and signed by the Administrator, documented that 110 residents resided in the facility. A review of the facility’s List of Staff In-services, covering the period from 8/8/24 through 8/25/25, showed no documentation that facility staff had received the required annual QAPI training. In an interview on 8/28/25 at 12:55 PM, the Administrative Assistant confirmed that no staff at the facility had received the annual QAPI training.
Widespread Failure to Document Medication Administration on MARs
Penalty
Summary
The deficiency involves the facility’s failure to document medications at the time of administration in accordance with its own Medication Administration policy, which requires staff to initial the Medication Administration Record (MAR) immediately after administering medications and prohibits pre‑signing or post‑signing. Surveyors’ review of MARs for multiple residents in August 2025 showed numerous missing documentation entries for ordered medications over multiple days. The Director of Nursing verified the missing documentation and stated that insufficient staffing contributed to staff not documenting medications administered. For one resident with Type 2 Diabetes Mellitus without complications, physician orders required Humulin R insulin with meals and Lantus SoloStar insulin twice daily. The MAR for this resident from August 1–27, 2025, showed that both Humulin R and Lantus SoloStar were not recorded as given on six separate dates. A registered nurse later stated that she had been the nurse for that resident on one of the affected weekends and did not know why she had not recorded administering those insulins. For eight additional residents, MARs dated August 2025 showed that numerous routine and PRN medications, including cardiovascular agents, psychotropics, inhalers, insulin, pain medications, and other chronic disease therapies, were not documented as administered multiple times throughout the month. For several of these residents, individual medications were not documented as given 5 or more times, and in many cases 7–10 or more times, between August 1 and August 25, 2025. These findings collectively demonstrate a pattern of failure to document medication administration as required by facility policy for all nine residents reviewed for medication administration.
Failure to Administer Ordered Topical Treatments for Skin Conditions
Penalty
Summary
The facility failed to provide physician-ordered topical treatments for a resident with psoriasis and excoriation. During observation, the resident was noted to have multiple round, red, raised, and flaky areas on both upper and lower extremities, and the resident reported having psoriasis and eczema that had recently worsened. The resident’s care plan documented psoriasis and directed staff to apply Nystatin powder to abdominal folds and triamcinolone as ordered. Physician orders included triamcinolone acetonide 0.1% cream to affected areas twice daily on weekdays for psoriasis and an antifungal powder to the abdominal folds three times daily for excoriation. Review of the MAR for August showed that the triamcinolone cream had not been administered at all since it was ordered and that the antifungal powder was not documented as given for 50 out of 73 scheduled doses. A RN and the DON confirmed that the blank MAR entries indicated the medications were not administered as ordered.
Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered, resulting in a 12% medication error rate (3 errors out of 25 opportunities), exceeding the 5% threshold. Facility policy on Medication Administration requires adherence to the seven rights and compliance with manufacturer specifications and professional standards, including shaking medications when indicated and following specific inhaler instructions. For one resident with asthma, the physician’s order for Albuterol Sulfate inhalation aerosol specified 2 puffs four times daily, with directions to shake well before administration and to have the resident rinse and spit afterward. During observation, an LPN handed the resident the Albuterol inhaler without shaking it, allowed the resident to take 2 puffs, and then returned the inhaler to the cart without instructing the resident to rinse and spit, despite the inhaler label including these directions. For a second resident with diabetes mellitus, the physician’s order for Insulin Lispro included a detailed sliding scale directing that a blood glucose of 356 or higher required administration of 20 units and a call to the MD. An LPN obtained a blood glucose result of 389 for this resident and administered only 18 units of Lispro insulin in the abdomen, later confirming that 20 units should have been given. For a third resident with diabetes mellitus, the physician’s orders included a fixed dose of 6 units of Insulin Aspart three times daily and a separate sliding scale that required 8 units for a blood glucose of 301–350. An RN obtained a blood glucose result of 348 and administered 14 units of Aspart insulin into the resident’s left upper arm using a vial that was confirmed to be expired. These observed deviations from physician orders and professional standards formed the basis of the cited medication administration deficiencies.
Failure to Date Opened Insulin Vials for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that opened insulin vials were dated in accordance with facility policy and accepted professional standards. For one resident, whose physician order sheet for August 2025 included Insulin Lispro 100 unit/mL to be given per sliding scale, an LPN prepared and administered 18 units of insulin from an opened insulin vial that had no date indicating when it was first accessed; the LPN confirmed she did not know when the vial was opened. For a second resident, also ordered Insulin Lispro 100 unit/mL per sliding scale, an RN prepared and administered 2 units of insulin from another opened, undated insulin vial and likewise stated she did not know when that vial was first accessed. The Director of Nursing later stated that the facility’s policy required insulin vials to be dated when first accessed and used for a period of 28 days, after which any remaining insulin should be discarded. The observations of staff administering insulin from undated vials, combined with staff statements that they did not know when the vials were opened, demonstrate that the facility did not follow its own policy for labeling and managing opened insulin vials for these two residents.
Failure to Accurately Document Ordered Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to maintain an accurate medical record by not documenting physician-ordered blood glucose testing for a resident with Diabetes Mellitus. The resident’s current Physician Order Sheet dated August 2025 included an order for Insulin Lispro 100 Unit/mL to be administered per sliding scale based on blood glucose monitoring before each meal, with a current order for fingerstick blood glucose monitoring twice daily. Review of the resident’s Medication Administration Record for August 1–25, 2025 showed that staff did not document the resident’s fingerstick blood glucose results on multiple dates, specifically August 6, 8, 10, 15, 17, 20, 21, 22, 23, and 24, 2025. During an interview on August 27, 2025 at 8:40 A.M., the DON confirmed the physician’s order for twice-daily fingerstick blood glucose monitoring and stated that staff were expected to perform the testing and record the results in the medical record for the physician to monitor the resident’s blood sugar levels. This lack of documentation of ordered blood glucose testing for a resident with Diabetes Mellitus constituted a failure to maintain an accurate medical record in accordance with accepted professional standards.
Failure to Properly Disinfect Shared Glucometer Between Residents
Penalty
Summary
Facility staff failed to follow the facility’s Glucometer Cleaning Policy and Procedure, dated 6/5/25, which requires disinfection of shared blood glucose monitoring equipment with a disinfecting wipe after each use and a 5-minute dry time. The deficiency involved two residents with physician orders for blood glucose monitoring three times daily (R8 and R103). On 8/25/2025 at 11:52 A.M., an LPN (V4) performed a finger-stick blood glucose test on R8 and then cleaned the shared glucometer with an alcohol pad instead of a disinfecting wipe, immediately placing the device in the top drawer of the medication cart without allowing the required disinfectant dry time. Seven minutes later, at 11:59 A.M., the same LPN used the same glucometer to perform a finger-stick blood glucose test on R103 and again cleaned the device only with an alcohol pad before returning it to the medication cart. On 8/27/2025 at 11:34 A.M., the DON (V2) confirmed that shared glucometers were required to be disinfected with a disinfecting wipe after each use, not an alcohol wipe. These observations, interviews, and record reviews showed that the facility did not implement its infection prevention and control program as written for disinfection of shared blood glucose monitoring equipment for two of two residents reviewed for blood glucose monitoring in a sample of 40.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
A resident with cognitive impairment was involved in a physical altercation with another resident who is alert and oriented but has a history of emotional regulation issues and aggressive behavior. The incident occurred when the cognitively impaired resident attempted to cut in line, prompting the other resident to push them, resulting in a fall. Both residents' care plans documented their respective behavioral and cognitive challenges, including poor impulse control and a tendency toward aggression. Despite the altercation, facility staff failed to notify the administrator or implement any interventions following the incident. The registered nurse did not report the event, and an investigation was not initiated until the administrator was informed at a later date. This lack of timely response and failure to follow abuse prevention protocols resulted in the facility not protecting the resident from physical abuse as required by policy.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the State Agency as required by its Abuse Prevention Program policy. According to the facility's policy, any suspicion or allegation of abuse, neglect, or exploitation must be immediately reported to the administrator or a designated individual in their absence, and the Department of Public Health's regional office must be informed. On 8/6/25, one resident was pushed by another resident, resulting in a fall and landing on the left side. Progress notes for both residents documented the altercation. However, the administrator confirmed that he was not notified of the incident, and as a result, no investigation or reporting to authorities occurred.
Failure to Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident physical abuse involving one of four residents reviewed for abuse. According to the facility's Abuse Prevention Program policy, the administrator or designee is required to initiate an incident investigation upon learning of any allegation of abuse. Progress notes for two residents documented that one resident pushed another, resulting in the second resident falling to the floor and landing on his left side. The administrator confirmed that he was not notified of the incident, and as a result, no investigation or reporting was conducted. The administrator also stated that all such incidents are supposed to be reported to him or his designee immediately, regardless of the time or day.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident sustaining a complex left hip fracture that required surgical intervention. One resident, who had diagnoses including schizophrenia, major depression, dementia, and chronic kidney disease, was involved in an altercation with another resident on the smoking patio. The altercation began with verbal exchanges and escalated when one resident pushed the other out of his wheelchair, causing him to fall onto the concrete and sustain a serious hip injury. Witnesses confirmed that the incident involved bickering, followed by one resident tipping the other out of the wheelchair. The injured resident was unable to stand due to pain and was subsequently sent to the emergency room, where a complex fracture was confirmed. The resident who initiated the altercation had a documented history of socially inappropriate behaviors, including verbal and physical aggression, and a delusional thought process affecting his awareness of safety for himself and others. The facility's Abuse Prevention Program defines abuse as the willful infliction of injury, and the incident was described by staff as an impulsive act rather than abuse. However, the event resulted in significant harm to the resident, and another resident was also struck in the face during the altercation. The report documents that the facility did not prevent the physical abuse between residents, as required by their policies.
Failure to Notify Law Enforcement After Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to notify local law enforcement following a physical altercation between two residents that resulted in injury. According to the facility's Abuse Prevention Program Facility Procedures, law enforcement must be contacted in cases of physical abuse involving injury, except when the behavior is associated with dementia or developmental disability. In this incident, one resident was found lying on the smoking patio, unable to stand due to pain, and was subsequently diagnosed with a complex fracture of the left hip. Progress notes indicated that the altercation stemmed from a verbal exchange, and the injured resident required emergency room evaluation. Despite these circumstances, the facility's Administrative Quality Assurance/Grievance/Abuse Coordinator confirmed that the police were not notified of the incident.
Failure to Investigate and Document Resident Exposure to Toxic Chemical
Penalty
Summary
The facility failed to investigate and document an incident in which residents were exposed to a toxic chemical in the dining room. According to the facility's policy, any incident or accident that could result in physical harm or emotional upset must be documented in the resident's medical record, and a nursing assessment should be completed. On the date of the incident, a registered nurse accidentally discharged a can of a chemical substance in the dining room, causing residents and staff to cough and experience eye irritation. Residents were evacuated, and emergency services were called, but no nursing assessments were performed or documented for the residents involved, including a cognitively intact resident who reported symptoms but was not assessed by a nurse. Multiple staff members, including RNs and an LPN, confirmed that no incident reports, resident assessments, or investigations were completed following the exposure. The Director of Nursing acknowledged that nursing assessments should have been completed and documented but were not. The facility was unable to identify which residents were present in the dining room at the time of the incident and could not provide any documentation of an investigation, witness statements, or incident reports related to the event.
Failure to Protect Resident from Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from mental and verbal abuse by a Certified Nursing Assistant (CNA), resulting in emotional distress and persistent fear for the resident. The CNA engaged in taunting behavior, including making derogatory remarks about the resident's significant other, sticking her tongue out at the resident, and making threatening gestures such as raising her fists and challenging the resident to a fight. Multiple staff and residents reported that the CNA was confrontational, demeaning, and had a pattern of inappropriate interactions with both residents and staff. The incident occurred in a public area of the facility, and the CNA's behavior was witnessed by other staff members, who described her actions as unprofessional and abusive. Despite the initial suspension of the CNA following the incident, her termination was rescinded due to union involvement, and she was allowed to return to work. This decision left residents and staff fearful, as the CNA continued to work in various areas of the facility, including the dining room and multiple halls. Interviews with several residents revealed that they felt intimidated, bullied, and harassed by the CNA, with some expressing fear of being around her and reluctance to report her behavior due to intimidation. Staff members also reported feeling uncomfortable and scared, with some stating that the CNA's behavior extended to her interactions with employees as well. The facility's own policies affirm the right of residents to be free from abuse and outline expectations for staff conduct, including the prohibition of verbal abuse and mistreatment. However, the facility failed to enforce these policies effectively, as evidenced by the CNA's continued employment and the lack of immediate protective measures for residents. The deficiency resulted in an Immediate Jeopardy situation, as residents experienced emotional harm and ongoing fear due to the CNA's actions and presence in the facility.
Removal Plan
- V3 completed Abuse training and Behavior De-escalation training and was monitored continuously on Second Shift.
- V3 was immediately terminated by V1 (ADM) and V2 (Director of Nursing/DON).
- V1 (ADM), V2 (DON) and V4 (Abuse Coordinator) completed an entire whole house audit to evaluate Facility Residents at risk for potential abuse and no evidence was noted.
- An all-Staff in-service by V1 (ADM) and V4 (Abuse Coordinator) was conducted on Resident Abuse and Reporting. A tracking sheet was expected to be completed.
- A sign was placed by the Facility timeclock to ensure employees complete the Abuse training prior to work on floor and direct care with Residents.
- A checklist was developed to ensure one-hundred percent compliance with the mandatory training for employees/staff that are on vacation and as needed basis (PRN).
- A current employee list was audited and over seen by V1 (ADM), V2 (DON) and V3 (Abuse Coordinator) to evaluate potential staff requiring one-on-one review and said employees to have additional training on Abuse and Mandatory Behavioral De-escalation courses.
- An Abuse training module through the Facility computer program was initiated with trainings on Abuse prevention, sensitivity and respect to be scheduled and implemented for part of the progressive disciplinary process.
- V1 (ADM), V4 (Abuse Coordinator) and Department Heads to monitor for compliance.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, R2, from physical abuse by another resident, R1, resulting in R2 receiving sutures for a facial laceration. The incident occurred in the TV area where both residents were present. R1, who has a history of psychotic disorder, mood disorder, unspecified dementia, anxiety, and traumatic brain injury, is noted to have severe cognitive impairment and poor impulse control. R1's care plan acknowledges the potential for verbal and physical aggression due to these conditions. On the day of the incident, R1 and R2 were involved in an altercation. R2, who also has unspecified dementia, anxiety, and schizoaffective disorder, is moderately cognitively impaired and prone to verbal and physical aggression. According to the progress notes, R2 and R1 began arguing, and as staff attempted to intervene, R1 stood up and struck R2 in the face, causing a laceration that required hospital treatment. The facility's abuse report confirms that R1's action was intentional, and video footage corroborates the sequence of events leading to the altercation. Staff interviews reveal that R1 becomes agitated by loud noises and yelling, which may have contributed to the incident. Despite staff presence, the intervention was not timely enough to prevent the physical altercation. The facility's abuse prevention policy emphasizes the protection of residents from abuse by anyone, including other residents, but in this case, the measures in place were insufficient to prevent the incident.
Failure to Prevent Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents with Traumatic Brain Injury (TBI) diagnoses. The incident occurred in the main dining room, where a verbal altercation between the two residents escalated into a physical confrontation. The altercation involved name-calling, slapping, scratching, and hair-pulling, resulting in one resident sustaining a scratch on the forehead. Despite multiple staff members being present, they were unable to intervene before the physical altercation occurred. The facility's undated Abuse Policy emphasizes the residents' right to be free from abuse, including physical abuse, and outlines the facility's commitment to preventing such occurrences. However, during the incident, one resident admitted to smacking the other in response to being verbally provoked. The staff members present did not hear the initial verbal exchange and were unable to prevent the physical altercation. The incident report noted that no first aid was required for the scratch sustained by the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately respond to repeated concerns raised by the Resident Council, affecting all 96 residents. The Resident Council Meeting Minutes from January to August 2024 consistently documented requests for larger meal portions, which were relayed to the dietary supervisor. However, residents reported that the serving sizes remained small, and requests for second helpings were often denied. This issue was a constant complaint, yet the Dietary Manager did not respond to these grievances, as confirmed by the Activity Director. Additionally, the Resident Council Meeting Minutes from February to August 2024 documented requests for more frequent interaction with the administration. Residents expressed difficulty in accessing the Administrator and desired more availability and willingness from the administration to assist them. Despite these repeated requests, the Administrator and some department managers did not address the concerns, leading to dissatisfaction among the residents. The facility's policy encourages open communication and prompt resolution of grievances, but the lack of response to these issues indicates a failure to adhere to this policy.
Failure to Implement Enhanced Barrier Precautions for MDRO Prevention
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs) among its 96 residents. The facility's policy on EBP, which is undated, outlines the use of gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with MDROs, as well as those at increased risk for MDRO acquisition. Despite this policy, observations on 9/17/24 revealed that no residents were in isolation, nor were there any signs indicating the implementation of EBPs on resident doors. On 9/19/24, the Director of Nursing/Infection Preventionist confirmed that the facility had not implemented EBP for any residents, despite having two residents with open wounds requiring dressing changes. The Director stated that the facility only used standard precautions and had recently received information about EBP from corporate but had not yet implemented it. This lack of implementation of EBP was confirmed despite the presence of residents with conditions that increase the risk of MDRO transmission, such as open wounds.
Failure to Prevent and Monitor Resident Abuse
Penalty
Summary
The facility failed to prevent and monitor residents for physical and verbal abuse, as evidenced by incidents involving four residents. The facility's abuse prevention policy, which aims to protect residents from abuse by anyone, was not effectively implemented. The policy outlines the need for a resident-sensitive environment and defines abuse as willful infliction of injury, including physical and verbal abuse. Despite these guidelines, incidents of abuse occurred, indicating a lapse in adherence to the policy. One significant incident involved a resident with a history of aggressive behavior and a criminal background, who was involved in physical altercations with another resident on two occasions. The first incident occurred on the smoking patio, where a verbal altercation escalated to physical violence, resulting in minor injuries to both residents. The second incident involved the same resident requesting a lighter from another resident, leading to a physical confrontation where the resident used a wheelchair to strike the other resident. Despite the facility's policy requiring supervision for this resident, the altercation occurred without staff intervention until after the incident had escalated. Another incident involved a verbal altercation between two residents in the dining room, which quickly escalated to a physical confrontation. Staff intervened immediately, but the incident highlights the facility's failure to monitor and prevent such altercations. The facility's initial report to the state agency documented the incident, but the investigation was still ongoing at the time of the report. These incidents demonstrate a failure to adequately supervise and protect residents from abuse, as required by the facility's policies.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed during an interaction between the resident and a staff member identified as V10 from Medical Records. The incident occurred when the resident, who had recently been hospitalized and had their diet order changed to a general diet, approached V10 to address the discrepancy in their meal. The resident calmly explained the situation, but V10 responded dismissively, instructing the resident to speak with their nurse and turning away to continue distributing trays to other residents. This interaction left the resident feeling upset and angry, as they felt they were being treated as problematic for simply wanting to ensure they received the correct meal. Further investigation revealed that V10 perceived the resident as aggressive and obsessive about their diet, although V10 could not specify any aggressive behavior during the interaction. V10 acknowledged that the resident's diet had indeed been changed to a general diet following their hospitalization. Despite being trained in de-escalation techniques, V10 admitted that the resident was not being aggressive at the time of the incident. This failure to treat the resident with dignity and respect, as outlined in the facility's Resident Dignity policy, contributed to the deficiency identified in the survey.
Failure to Assist Resident with Desired Transfer
Penalty
Summary
The facility failed to assist a resident, identified as R93, in finding an alternate nursing home placement, which was a deficiency noted during a survey. The facility's admission packet outlines that the Social Service Department is responsible for discharge planning and should be contacted when a resident considers leaving. Despite this, R93 expressed dissatisfaction with the current facility and a desire to return to a previous long-term care facility. The resident communicated this wish to various staff members, but no action was taken to facilitate the transfer. The administrator, identified as V1, acknowledged that R93 had expressed a desire to return to the previous facility but did not document any attempts to initiate the transfer process. The administrator of the previous facility confirmed that no requests for rescreening or reassessment of R93 had been received. This lack of action and documentation indicates a failure to support the resident's right to self-determination and choice in their living arrangements, as outlined in the facility's discharge planning policy.
Failure to Update PASARR for Residents with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) process was updated for two residents diagnosed with psychiatric conditions after their admission. Resident 8 was admitted without a documented psychiatric diagnosis, but later received a diagnosis of Schizoaffective Disorder, Bipolar Type. Despite this, the facility did not update the Level I PASARR to determine the need for a Level II PASARR. Similarly, Resident 67 was admitted without a psychiatric diagnosis, but was later diagnosed with Other Schizoaffective Disorders following a psychiatric visit. The facility again failed to update the PASARR screening to reflect this change. The Quality Assurance staff member, identified as V4, confirmed the lack of updated screenings for both residents.
Failure to Update Code Status Leads to Unwanted CPR
Penalty
Summary
The facility failed to update a resident's chart to reflect a change in code status from Full Code to Modified DNR, resulting in the resident receiving full CPR, including chest compressions, contrary to their wishes. The resident, identified as R99, had a POLST indicating a Modified DNAR, which specified non-invasive airway and breathing support, IV medications, and hospital transfer, but explicitly stated no chest compressions. However, the care plan still documented the resident as Full Code, and it was only updated to reflect the DNR status a day after the resident's death. The incident occurred when R99 was found unresponsive, and the LPN on duty used an ambu-bag until EMS arrived. The LPN was distracted and did not inform EMS of the DNR status, and the CNA who called 911 was unaware of the change in code status, leading to the dispatcher being informed that the resident was Full Code. Consequently, EMS performed chest compressions and other resuscitative measures. The resident's Health Care Power of Attorney confirmed that R99 had changed their code status while in the hospital, but this was not reflected in the facility's records at the time of the incident.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide therapy services as ordered for a resident with limited range of motion. The resident, who was observed with left upper extremity weakness and lack of coordination, had a physician's order for referrals to outpatient speech therapy, physical therapy, and occupational therapy. Despite being admitted to the facility for six weeks, the resident reported not receiving any therapy services and had to arrange for therapy with the help of his mother. The resident's Power of Attorney confirmed that no referral for therapy services had been received by the outside physical therapy department, and the lack of therapy was affecting the resident's ability to progress in his diet. The Restorative Nurse acknowledged the delay in treatment and confirmed that the resident was not on a formal restorative program to prevent further decline in range of motion while awaiting therapy evaluations.
Failure to Implement Dietician's Recommendations for Resident's Weight Loss
Penalty
Summary
The facility failed to follow the registered dietician's recommendations to prevent weight loss for a resident identified as R75. The facility's weight policy and procedure require that any dietary recommendations made by the dietician be referred to the physician for approval. However, despite significant weight loss documented over several months, there were no diet supplements or dietary recommendations included in R75's physician orders. The resident's weight declined from 190 lbs in November 2023 to 159.2 lbs by September 2024, indicating a significant weight loss of 10.3% over three months. The registered dietician had recommended changes to R75's diet, including substituting a sandwich and milk at bedtime with pudding and a thickened health shake, and providing a honey-thick health shake with breakfast and lunch, but these recommendations were not implemented. Observations and interviews revealed that R75 was not receiving the recommended dietary supplements. R75 expressed awareness of his weight loss and mentioned not receiving milkshakes, which he would drink if provided. Staff members, including an RN and an LPN, were unaware of any special supplements being provided to R75, despite the resident's significant weight loss and dietary needs. The facility's Director of Nursing stated that weight meetings were held weekly to discuss resident weight losses and interventions, but it appears that the necessary dietary interventions for R75 were not effectively implemented or communicated to the staff responsible for the resident's care.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the survey inspection book contained three years of previous survey results for both complaint and certification inspections. This deficiency was identified during a resident group meeting where several residents confirmed they were unaware of where to access the facility's previous annual and complaint investigation results. Additionally, they did not know that the State Agency survey results were available for their review. The facility had posted a notice on the main hall bulletin board indicating that survey results were available in the survey room, but access required assistance if the room was locked. Upon inspection, the survey results book was found behind the reception/security front desk and contained only the annual Licensure and Certification survey dated 6/2023. It lacked any complaint survey results or annual Certification surveys from the previous three years, except for the 2023 survey. The Quality Assurance representative confirmed the limited contents of the book and explained that it was kept in the family room or behind the security front desk, with access provided upon request. The family room was not always unlocked, as it was locked at night to prevent theft.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a vulnerable resident (R1) from resident-to-resident abuse on two separate occasions. R1, who has a history of Traumatic Brain Injury and is known to become agitated with loud noises and overstimulation, was involved in physical altercations with other residents on 4/7/2024 and 4/11/2024. On 4/7/2024, R1 argued with a female resident (R2) and punched her in the face, leading R2 to retaliate by hitting R1 with a chair, causing a laceration and nasal fracture. Despite being placed on 15-minute checks after this incident, R1 was involved in another altercation on 4/11/2024 with his roommate (R3), who attacked R1 for being in his bed, resulting in multiple injuries to R1's head and back. The facility's failure to maintain the 15-minute monitoring for R1 contributed to these incidents of abuse. R1's care plan, which included interventions such as removing R1 to a quiet area to de-escalate agitation and conducting 15-minute checks, was not effectively implemented. On 4/7/2024, there was no staff present in the dining room when R1 and R2 began fighting, and staff only intervened after the altercation had escalated. Similarly, on 4/11/2024, R1 was not on the required 15-minute checks when R3 attacked him in their shared room. The facility's Director of Nurses (DON) and other staff members acknowledged R1's impulsive behavior and susceptibility to overstimulation but failed to provide the necessary supervision and intervention to prevent these incidents. Interviews with staff members revealed that they were aware of R1's triggers and the need for close monitoring, yet the facility did not ensure that these measures were consistently followed. The lack of staff presence in the dining room and the failure to conduct 15-minute checks allowed the altercations to occur and escalate, resulting in injuries to R1. The facility's inability to protect R1 from abuse and maintain the prescribed interventions led to the determination of Immediate Jeopardy, which was later removed, but the facility remained out of compliance at a severity level two.
Removal Plan
- The facility has re-assessed R1 as being high risk for abuse and the assessment for R1 has been added to R1's Care plan.
- The facility has informed all staff that there is to be one staff member in the main dining room prior to serving meals when the residents are coming into the dining room. This will provide supervision to maintain a safe environment and prevent resident abuse for all residents.
- The facility did an all staff in-service to educate all staff on R1's high risk for abuse from other residents. They also educated all staff on the potential behaviors inducing triggers and provided education to protect all residents from resident abuse.
- The facility has started to develop a QA/QAA plan for increased monitoring of resident safety prior to the serving of resident meals.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 Elms | 0.1 mi | ★★★★★ | 10 | 1 |
| Sharon Health Care Willows | 0.1 mi | ★★★★★ | 5 | 0 |
| Loft Rehab Of Peoria, The | 2.5 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.