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 Willows during CMS and state inspections, most recent first.
Two residents with significant psychiatric and cognitive conditions, including schizoaffective disorder, antisocial personality disorder, DiGeorge Syndrome, and hearing loss, became involved in a physical altercation in the dining room after one took the other’s cup. As both residents pulled at the cup, the aggressive resident punched the other in the face, with staff witnesses reporting one or two closed-fist strikes. Documentation in the medical record and facility-reported incident forms confirms the physical abuse, which occurred despite existing care plans noting one resident’s history of battery and potential for physical aggression, and in the context of a facility abuse prevention policy that prohibits physical abuse such as hitting.
The facility failed to prevent multiple incidents of resident-to-resident physical and sexual abuse involving individuals with known behavioral and psychiatric histories. A resident with schizophrenia and bipolar disorder reported being slapped and later having her breast and back touched without consent in a dining room by a peer with a documented history of inappropriate sexual behavior, with staff witnessing the contact and the resident’s verbal objections. In separate events, a resident with a criminal history of violent offenses admitted to striking another resident in the mouth, and another resident with schizoaffective disorder, daily yelling behaviors, hallucinations, and potential for physical aggression punched a peer in the mouth, causing a lip laceration and swelling, all occurring in common areas despite known risks.
The facility failed to notify local police of several resident-to-resident abuse incidents. In one event, a resident struck another in the face with a closed fist, causing a lip laceration, and police were not contacted. In another, a resident hit a peer in the mouth in a dining room and admitted doing so, yet law enforcement was not notified. In a separate incident, a resident reported that a peer touched her breast and lower side without consent, with no documentation of police notification. The Administrator confirmed that police are only contacted when there is a serious injury, resulting in these physical and sexual abuse allegations not being reported to law enforcement.
A resident gave an Activity Director his debit card to buy tobacco and pay a court fine, but the card was taken home, misplaced, and never returned. The resident’s account was then drained by multiple ATM, gambling, food, tobacco, clothing, and cash transactions, leaving the balance negative. The resident reported the loss caused many problems and mental distress, and police were notified.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents who required supervision while smoking were left unsupervised on the patio during a scheduled smoke break, resulting in an altercation. Care plans and facility policy specified the need for staff monitoring, but interviews and documentation confirmed that no staff were present at the time, and that this lack of supervision had occurred previously.
Multiple residents with cognitive and psychiatric conditions were involved in physical altercations, including hitting and pushing, resulting in injuries such as a wrist fracture and facial scratches. These incidents occurred in common areas like hallways and dining rooms, and were witnessed by staff, but residents were not adequately protected from physical abuse by peers.
A resident with multiple medical conditions and a history of falls slipped on a wet floor after attempting to get up unassisted to use the bathroom. Although a CNA noticed the spill and instructed the resident not to get up, the CNA left the room to get cleaning supplies without ensuring supervision or activating the call light. The resident fell and sustained a fractured femur requiring surgery. The facility failed to provide adequate supervision and promptly address the environmental hazard, resulting in significant injury.
A resident with a history of PTSD reported repeated sexual harassment and inappropriate gestures from another resident with a known history of such behaviors. Despite multiple reports to the administrator and staff, the facility's response was limited to redirection, with no documentation or effective intervention, resulting in continued distress for the affected resident.
A resident with a history of inappropriate sexual behavior repeatedly made sexual gestures and verbal advances toward another cognitively intact resident, who reported distress and a history of PTSD. Despite multiple reports to the Administrator and staff, the incidents were not documented or reported to the state agency as required by facility policy.
A resident with a history of PTSD reported repeated sexual harassment and gestures from another resident to the administrator and staff over several months, but no investigation or documentation was completed as required by facility policy.
A resident was struck on the back of the head by another resident in the dining room after a dispute over wheelchair positioning. Staff and security witnessed the incident, and documentation confirmed that the physical contact constituted abuse as defined by facility policy.
Multiple residents with cognitive and psychiatric conditions were involved in repeated physical altercations, including hitting, biting, and tipping wheelchairs, resulting in injuries such as bruises and lacerations. Staff were not always able to intervene in time to prevent harm, and some residents were involved in multiple incidents. The facility did not effectively prevent episodes of physical abuse among residents.
Several residents with behavioral and cognitive disorders engaged in physical altercations, including hitting, biting, and tipping wheelchairs, due to the facility's failure to implement adequate monitoring and behavioral interventions. Despite known histories of aggression and care plans outlining the need for supervision and redirection, staff did not consistently intervene or increase monitoring, resulting in repeated episodes of physical abuse.
Two residents, both cognitively intact and with histories of aggression, were involved in a physical altercation resulting in one resident sustaining a nasal fracture. The incident occurred on the facility's patio, and the aggressor was taken to jail by police. The facility's abuse prevention policy failed to prevent this incident.
The facility's kitchen failed to maintain proper sanitation and food safety standards, with issues including improperly mixed sanitizing solutions, uncovered trash bins near food prep areas, and unsanitary handling of ice. The sanitizing solution was found to be outside the acceptable range, and trash cans were left open and near food preparation areas. Additionally, the ice scoop was stored in an unsanitary manner, and a resident was observed using it with bare hands. These deficiencies could potentially affect all 115 residents.
The facility failed to update care plans for two residents with mental health disorders. One resident with schizophrenia experienced hallucinations but had no documented behaviors or non-pharmacological interventions in their care plan. Another resident with schizoaffective disorder exhibited yelling behaviors, yet their care plan also lacked documentation of targeted behaviors and interventions. These deficiencies were confirmed by the RN Care Plan Coordinator.
The facility failed to implement a range of motion (ROM) program for three residents with functional limitations, as required by their Restorative Program Policy. These residents, observed with limitations in their range of motion, did not have individualized care plans addressing these needs. A CNA confirmed that these residents were not receiving any active or passive ROM therapies, indicating a failure to adhere to the facility's policy.
A facility failed to implement non-pharmacological interventions and did not document or track behaviors for a resident prescribed psychotropic medications. Despite the resident reporting hallucinations, the medical record lacked documentation of behaviors or interventions, contrary to facility policy. A nurse confirmed the absence of necessary documentation.
A resident's wound care was compromised when an RN failed to sanitize scissors between uses, leading to potential cross-contamination. The RN used the same unsanitized scissors to cut dressings for multiple wounds, despite the presence of fecal matter on the drape beneath the resident. This breach of infection control protocols occurred during a scheduled dressing change, observed by another RN and the Infection Control Preventionist.
The facility failed to protect residents from physical abuse in two incidents. In one case, a resident was kicked by another, causing a fall. In another, a resident with Schizophrenia and Bipolar Type pushed another resident to the ground. Despite the facility's abuse prevention policy, these incidents occurred, indicating a deficiency in safeguarding residents.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse between two residents with known psychiatric and behavioral histories. One resident (R1) has DiGeorge Syndrome with intellectual and cognitive deficiencies, schizoaffective disorder, major depression, anxiety, epilepsy, and documented hearing loss. Another resident (R2) has antisocial personality disorder, schizoaffective disorder, and post-traumatic stress disorder, with a care plan documenting a history of battery and the potential to be physically aggressive and cause property damage due to poor impulse control. On the date of the incident, in the North Dining Room, R1 picked up or had possession of R2’s cup. Accounts in the record and staff interviews indicate that R2 attempted to retrieve the cup, both residents pulled at it, and R2 then struck R1 in the face. The facility’s Facility Reported Incident (FRI) and Incident/Accident Report document that R2 hit R1 on the left side of the face with a closed fist, with one report noting R2’s statement that R1 “snatched my cup” and that R2 punched R1 once in the face. Staff interviews provide additional detail, with one CNA stating she saw R1 pick up R2’s cup and then observed R2 punch R1 in the face twice, and another CNA stating that R2 took the cup back, R1 grabbed it, and R2 punched her in the face. R1 was assessed with no injuries or complaints of pain noted. The facility’s Abuse Prevention Program policy affirms residents’ rights to be free from abuse and defines abuse as any physical or mental injury inflicted upon a resident other than by accidental means, including hitting and slapping, which aligns with the physical altercation that occurred between these two residents.
Failure to Prevent Resident-to-Resident Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to prevent physical and sexual abuse among residents with known behavioral and psychiatric histories. One resident with schizophrenia and bipolar disorder reported being slapped in the face in the dining room and later stated that another resident had grabbed her breast there. A CNA heard the resident yell for the other resident to stop touching her and observed the peer touching her breast and lower back. The same day, the peer resident walked behind her, made a suggestive verbal remark, and attempted to kiss the top of her head, prompting the resident to yell and staff to intervene. The peer resident’s care plan documented a history of inappropriate sexual behavior, yet the incidents occurred in a common area where contact and sexualized behavior were observed by staff. Additional incidents of physical abuse occurred between other residents with documented behavioral risks. In one event, a resident with a criminal history including domestic battery, aggravated battery, and battery admitted to hitting another resident in the mouth with an open hand after complaining about the other resident’s statements; staff heard the victim yell that she had been hit and then separated the two. In another event in a dining room, a resident with schizoaffective disorder, daily yelling behaviors, hallucinations, and a history of potential physical aggression punched another resident in the mouth with a closed fist, causing a lip laceration and swelling. Staff statements and care plans confirmed that this resident frequently yelled out, could be physically aggressive, and was resistant to redirection, yet the assault still occurred in a common area where both residents were present.
Failure to Notify Police of Resident-to-Resident Physical and Sexual Abuse Allegations
Penalty
Summary
The facility failed to notify local law enforcement of multiple allegations of physical and sexual abuse between residents. An incident report dated 12/29/25 documented that at 9:15 a.m. one resident (R5) hit another resident (R6) in the face with a closed fist, causing a cut on R6’s lip, and the form showed that police were not notified. Another incident report dated 1/27/26 documented that at 1:10 p.m. in the North dining room, one resident (R3) hit another resident (R4) in the mouth with an open hand; staff separated the residents after R4 alerted them, and R3 admitted to hitting R4, but the report documented that police were not notified of this physical altercation. A separate incident/accident report dated 2/6/26 documented that R4 reported a peer (R7) touched her breast and lower side without her consent, and this form contained no documentation that local police were notified of the unwanted touching. On 2/9/26 at 10:30 a.m., during an interview, the Administrator (V1) confirmed that the facility does not notify police of any physical or sexual incidents unless there is a serious injury, corroborating that law enforcement was not contacted for these reported incidents of resident-to-resident physical and sexual abuse.
Misappropriation of Resident Debit Card and Unauthorized Spending
Penalty
Summary
The Facility failed to establish procedures to purchase a resident’s personal items and failed to prevent staff from the unauthorized use and theft of a resident’s debit card without the resident’s permission. The deficiency involved one of four residents reviewed for misappropriation of resident property. The Facility’s Abuse Prevention Program Policy and Resident Rights Policy stated that residents are to be protected from abuse and misappropriation of property and that the Facility may not become a resident’s money manager without permission. R2 gave V3, the Activity Director, R2’s personal debit card to purchase tobacco products and to pay a court fine. V3 purchased the wrong tobacco flavor, then left again with the debit card to get the correct product. V3 did not return the card, later told R2 the card had been lost, and told R2 that a replacement card had been ordered. R2 stated that V3 took the debit card home over the weekend and lost it while moving. V3 stated that part of the job was to shop for residents, that V3 misplaced R2’s debit card over the weekend while moving, and that V3 did not remember exactly when it happened. R2’s debit card statements showed the account balance dropping from about $2,600 to a negative balance, with multiple transactions in August 2025 including local bank withdrawals, food and tobacco purchases, ATM withdrawals, gambling/video gaming facility charges, clothing store charges, and a gas station cash purchase. R2 stated that the card was never found, that a new card was eventually obtained by someone else, and that the incident caused many problems and mental distress. The police were notified and an investigation was initiated. R2’s diagnoses included Antisocial Personality Disorder, Schizoaffective Disorder, and Post-Traumatic Stress Disorder.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Supervise Residents During Scheduled Smoking Breaks
Penalty
Summary
The facility failed to monitor, supervise, and follow its own policy to ensure a safe smoking environment for two residents who were identified as requiring supervision while smoking. Both residents had care plans specifying the need for staff supervision and assistance during smoking breaks to maintain safety. Despite these documented requirements, on the date of the incident, both residents were left unsupervised on the facility's patio during a scheduled smoke break, which resulted in an altercation between them. Multiple interviews with other residents and staff confirmed that no staff were present on the patio at the time of the incident, and that this lack of supervision had occurred during previous smoke breaks as well. The facility's Smoking Safety Policy and Procedure required that patients in the supervised smoking program receive assistance and monitoring to maintain safety. Scheduled smoke breaks were assigned to specific staff members, but on the day of the incident, the designated staff member was not present due to being called away for another task. Staff interviews acknowledged that supervision was not provided as required, and that both residents involved were not independent smokers and should have been monitored according to their care plans and facility policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from episodes of physical abuse perpetrated by other residents. Several incidents were documented in which residents with cognitive and psychiatric diagnoses engaged in physical altercations, resulting in injuries. In one instance, a female resident with schizoaffective disorder and intact cognition was struck on the jaw by a male peer with Alzheimer's disease and moderate cognitive impairment while she was in her wheelchair in the hallway. Witness statements confirmed that the male resident became agitated, yelled, and hit the female resident with a closed fist. No injuries were noted, and the resident denied pain or discomfort at the time. Another incident involved a cognitively intact female resident with multiple psychiatric diagnoses who was pushed to the ground by a male resident with moderate cognitive impairment during a struggle over snacks in the dining room. The female resident sustained a displaced fracture of the distal radial metaphysis in her right wrist, as confirmed by x-ray. Witnesses, including a registered nurse, observed the altercation and confirmed that the male resident pushed the female resident after both attempted to take possession of the snack. The injured resident later reported significant pain in her wrist. Additional altercations were documented, including an incident in which a female resident attempted to take another resident's belongings, resulting in a physical confrontation where one resident was pushed and then struck in the face. Another event involved a resident being pushed to the ground after reaching for another resident's cup. These repeated episodes of resident-to-resident physical abuse occurred despite the facility's abuse prevention policy, which affirms residents' rights to be free from abuse and outlines the facility's commitment to preventing mistreatment. The documented incidents demonstrate a failure to prevent and protect residents from physical abuse by peers.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Environmental Hazard
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Bipolar Disorder, COPD, metabolic encephalopathy, and a right artificial shoulder joint, experienced a fall resulting in a fractured femur. The resident was assessed as having intact cognition but exhibited delusions and impulsive behaviors, and required supervision for all activities of daily living and toileting. The care plan identified the resident as being at risk for falls, with a history of wheelchair use and independent ambulation. On the night of the incident, the resident attempted to get up from bed to use the bathroom and slipped on a wet floor caused by a spilled cup of water. A CNA observed the water on the floor and instructed the resident not to get up while she left the room to obtain cleaning supplies. Despite these instructions, the resident attempted to stand and subsequently fell, sustaining a comminuted and displaced distal femur fracture that required surgical intervention. The CNA later acknowledged that she should have ensured someone stayed with the resident or activated the call light until the hazard was addressed. Facility policy required routine assessment of the care environment for extrinsic risk factors and prompt corrective action to prevent falls. However, the failure to provide adequate supervision and to immediately address the environmental hazard directly contributed to the resident's fall and injury. The incident investigation identified the wet floor and the resident's impulsivity as contributing factors, and staff interviews confirmed that supervision was insufficient at the time of the event.
Failure to Protect Resident from Ongoing Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by repeated incidents involving inappropriate sexual gestures and verbal sexual advances from another resident. One resident, who is cognitively intact and has a history of PTSD due to childhood sexual trauma, reported that another cognitively intact resident with a documented history of inappropriate sexual behaviors persistently made sexual gestures and explicit sexual comments towards her. These behaviors included making suggestive hand gestures, verbalizing sexual intentions, and making inappropriate remarks in the presence of others. The affected resident reported these incidents multiple times to the facility administrator and other staff members, expressing distress and discomfort. Despite these reports, the administrator acknowledged being aware of the ongoing inappropriate behaviors but did not document the complaints or take effective action beyond instructing staff to redirect the offending resident. Staff interviews confirmed that the inappropriate behaviors were witnessed and reported to facility leadership, yet the response was limited to redirection without further intervention or documentation. The facility's own Abuse Prevention Program defines such conduct as sexual abuse, including sexual harassment and coercion, but the policy was not effectively implemented to protect the resident from ongoing abuse.
Failure to Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report allegations of potential resident-to-resident sexual abuse to the Administrator and the state agency as required. One resident, who is cognitively intact and has a documented history of inappropriate sexual behaviors, repeatedly made sexual gestures and verbal advances toward another cognitively intact resident. The affected resident reported feeling upset and stated that the behavior was ongoing, including explicit gestures and repeated verbal requests for sex, which she had asked to stop multiple times. She also disclosed a history of PTSD related to childhood sexual trauma. Despite reporting these incidents to the Administrator and other staff members on multiple occasions, the only action taken was to redirect the offending resident, and no formal documentation or external reporting occurred. Multiple staff members, including a restorative aide, social services, and a housekeeper, witnessed or were informed of the inappropriate behaviors and comments but did not escalate the reports to the Administrator or the state agency as required by the facility's abuse prevention policy. The Administrator acknowledged being aware of the allegations but did not document the reports or notify the state agency. The facility's policy mandates immediate reporting of abuse allegations to the state agency and the resident's representative, but this protocol was not followed in this case.
Failure to Investigate Resident's Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct an investigation after a resident reported ongoing sexual harassment and inappropriate sexual gestures from another resident. The affected resident, who has a history of PTSD due to childhood sexual assault, stated that the other resident repeatedly made sexual gestures and verbal propositions, despite being told to stop. The resident reported these incidents to the facility administrator and other staff members multiple times over several months, but no documentation or investigation was initiated in response to these allegations. The administrator confirmed that the resident had reported the inappropriate behavior on several occasions but admitted that neither documentation nor an investigation was completed. The facility's Abuse Prevention Program Policy requires that all allegations of abuse, including sexual harassment, be documented and investigated. However, in this case, the required procedures were not followed, and there was no evidence of any attempt to interview involved parties or review relevant documentation as outlined in the policy.
Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident in the facility's dining room. According to the facility's Incident Investigation Report and nursing progress notes, one resident wheeled up to a table where another resident was sitting. The seated resident expressed that the other resident kept running into his wheelchair and, in response, struck the other resident on the back of the head with an open hand. Staff and security present in the dining room witnessed the incident, and the event was documented by the nurse on duty and reported to the facility administrator. The facility's Abuse Prevention Program policy defines abuse as any physical or mental injury inflicted upon a resident other than by accidental means. The incident involved physical contact that resulted in harm, which meets the facility's definition of abuse. The report confirms that the residents were separated following the altercation, and the incident was verified by both the administrator and the nurse on duty.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from episodes of physical abuse over a period of several months, as evidenced by repeated incidents of resident-to-resident aggression resulting in physical harm. In numerous documented cases, residents with cognitive impairments, such as dementia or severe memory problems, were involved in altercations where they were either the aggressor or the victim. These incidents occurred in various locations throughout the facility, including hallways, dining rooms, and resident rooms, and involved behaviors such as hitting, punching, biting, and tipping wheelchairs. In several cases, residents sustained injuries such as lacerations, bruising, and bleeding, and some required evaluation at a hospital. The report details that staff were present or nearby during many of these incidents but were not always able to intervene in time to prevent physical harm. For example, in one case, a resident with impaired cognition was struck multiple times in the face by another resident before staff could separate them. In another instance, a resident was punched in the face and fell to the ground after an unprovoked attack in the dining room. There were also situations where residents with known behavioral issues or histories of aggression were not adequately monitored or redirected, leading to repeated altercations with peers. The residents involved often had significant psychiatric or neurocognitive diagnoses, such as dementia, schizoaffective disorder, or anxiety disorders, which contributed to their behaviors and vulnerability. The facility's own documentation and staff interviews confirm that these incidents were not isolated and that some residents were involved in multiple episodes of aggression, both as victims and perpetrators. Despite the facility's stated policy to protect residents from abuse and maintain a secure environment, the frequency and nature of these events demonstrate a failure to prevent physical abuse among residents.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to implement adequate behavioral interventions and supervision to prevent episodes of physical abuse among residents with known behavioral and cognitive disorders. Multiple incidents occurred in which residents with histories of aggression, psychiatric diagnoses, or cognitive impairment engaged in physical altercations with peers. In several cases, staff did not initiate increased monitoring, such as 15-minute checks or one-to-one supervision, despite documented increases in aggressive behaviors and prior incidents. One resident with anxiety, delusional disorder, and a criminal background was involved in multiple altercations, including attempting to kiss and biting a peer, and later engaging in a physical fight with another resident. Despite escalating behaviors and recommendations for medication review, staff did not implement increased monitoring prior to the altercation. Another resident with schizoaffective disorder and a history of physical aggression tipped another resident's wheelchair on two separate occasions, causing the other resident to fall. Staff were expected to monitor and redirect these residents but failed to do so effectively, resulting in repeated incidents. Additional incidents included a resident with Alzheimer's disease and wandering behaviors colliding with another resident, leading to a physical altercation, and a resident striking a peer in the face after being agitated by disruptive wheelchair behavior during meals. In each case, the residents involved had care plans that identified their behavioral risks and outlined interventions such as redirection and monitoring. However, staff did not consistently implement these interventions, and the lack of proactive supervision and timely behavioral management contributed to the occurrence of physical abuse between residents.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, resulting in one resident sustaining a nasal fracture and other injuries. The incident involved two residents, both of whom were documented as cognitively intact. One resident had a history of verbal aggression escalating to physical threats, while the other had a history of physical aggression towards peers. On the day of the incident, a Certified Nursing Assistant (CNA) was alerted to a fight on the patio, where one resident was found on top of the other, hitting him in the face. The injured resident was subsequently transported to the Emergency Department for evaluation and treatment of a nasal fracture. The facility's abuse prevention policy emphasizes the protection of residents from abuse by anyone, including other residents. However, the altercation occurred despite this policy, indicating a failure in its implementation. The police were involved, and the aggressor was given the option of going to jail or the hospital, ultimately being taken to jail. The facility's reports document the incident and the injuries sustained, but do not provide information on preventive measures that were in place or actions taken to prevent such incidents.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation standards in its kitchen, as evidenced by several observations and interviews. The sanitizing solution used to clean food preparation surfaces was found to be improperly mixed, with one instance measuring only 10 ppm and another exceeding 200 ppm, both outside the acceptable range of 100-200 ppm. Additionally, the facility did not consistently document the checks of the sanitizing solution, as required by their procedures. This lack of proper sanitation practices was confirmed by the Dietary Manager, who acknowledged the discrepancies in the solution's concentration and the absence of recorded checks. The facility also failed to adhere to its waste disposal policy, which mandates that trash bins be covered and kept away from food preparation areas. Observations revealed multiple open trash cans in the kitchen, some placed near food preparation areas such as the steam table and grill. The Dietary Manager and a Dietary Aide confirmed the absence of lids for these trash cans, with the aide noting that lids had not been used in the five years of their employment. This oversight in waste management practices was further compounded by the unsanitary condition of the kitchen floor, which was observed to be dirty, sticky, and littered with debris, including a yellow slime-like substance and a brown gritty material. Furthermore, the facility's handling of ice was found to be inadequate, as the ice scoop used for kitchen purposes was stored in an unsanitary manner. The scoop was left open to air on a cart with unknown particles and debris, and a resident was observed using the scoop with bare hands to fill a personal cup. The Dietary Manager confirmed that this was the only scoop used for kitchen ice purposes and attempted to address the issue by placing the scoop on a tray. These deficiencies in sanitation and food safety practices have the potential to affect all 115 residents living in the facility.
Failure to Update Care Plans for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to update the care plans for two residents, both of whom were diagnosed with mental health disorders. The first resident, who was alert and oriented, had schizophrenia and was on multiple medications for anxiety and depression. Despite the resident's admission of experiencing hallucinations that prompted self-harm thoughts, the care plan did not document any targeted behaviors or non-pharmacological interventions. This oversight was confirmed by the Registered Nurse Care Plan Coordinator. The second resident had schizoaffective disorder and altered mental status but was not on any psychological medications. This resident exhibited behaviors such as yelling and slamming doors, which were observed by the surveyor and confirmed by a Certified Nurse Aid. However, the care plan for this resident also lacked documentation of targeted behaviors and non-pharmacological interventions. The Registered Nurse Care Plan Coordinator verified this deficiency as well.
Failure to Implement Range of Motion Program for Residents
Penalty
Summary
The facility failed to implement a range of motion (ROM) program for residents with functional limitations, as required by their own Restorative Program Policy. This deficiency was identified for three residents, who were observed to have limitations in their range of motion but did not have individualized care plans addressing these needs. Resident 8 was observed in a contracted fetal position, with documented impairments in bilateral lower extremities, yet lacked a care plan for ROM interventions. Similarly, Resident 47, who relied on staff for mobility and had impairments in bilateral lower extremities, reported not receiving any exercises or ROM assistance, and her care plan also lacked documentation for ROM interventions. Resident 90, diagnosed with Huntington's Disease and Primary Osteoarthritis, was observed with spastic movements and contracted arms, indicating limitations in both upper and lower extremities. Despite these observations, her care plan did not include a ROM program to address these limitations. The Rehabilitation Aide/CNA confirmed that these residents were not on the list for restorative care and were not receiving any active or passive ROM therapies. This oversight indicates a failure to adhere to the facility's policy of providing appropriate treatment and services to maintain or improve residents' abilities.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions and did not identify, document, or track behaviors for a resident who was prescribed psychotropic medications. The facility's policy on psychotropic medication requires that each medication is tracked for behaviors, mood, and depression, and that non-pharmacological approaches are attempted before resorting to medication. However, for one resident with schizophrenia, there was no documentation of behaviors or non-pharmacological interventions in the medical record, despite the resident being prescribed multiple psychotropic medications, including Lorazepam, Zoloft, Risperidone, Olanzapine, and Trazodone. Observations made over several days showed the resident without any noted behaviors, but during an interview, the resident reported experiencing hallucinations that prompted self-harm thoughts. The medical record lacked documentation of these behaviors or any non-pharmacological interventions. A registered nurse confirmed the absence of targeted behaviors and interventions in the resident's medical record, and a certified nurse aide mentioned that behaviors are typically charted in their online system, which was not reflected in this case.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control during a resident's wound care, leading to potential cross-contamination. The resident, who had multiple wounds on the right leg, was receiving treatment for skin integrity issues related to urinary incontinence and limited mobility. During a scheduled dressing change, a registered nurse (RN) used unsanitized scissors to cut dressings for the resident's wounds, despite the presence of fecal matter on the disposable drape beneath the resident. The RN did not sanitize the scissors between uses, which were used to cut both the hip/thigh and calf dressings, and also reused a piece of calcium alginate that had fallen onto the contaminated drape. The RN acknowledged the oversight, admitting that she did not consider sanitizing the scissors during the wound care process. The facility's policy required adherence to universal precautions and clean techniques for wound care, but these were not followed. The incident was observed by another RN and the facility's Infection Control Preventionist, who were present during the procedure. The failure to maintain a clean field and sanitize equipment during wound care posed a risk of wound contamination for the resident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving residents. In the first incident, a resident was involved in a physical altercation on the patio area, where one resident kicked another, causing the latter to fall. Witnesses confirmed the altercation, and the facility's administrator acknowledged the incident. In the second incident, a resident with a diagnosis of Schizophrenia and Bipolar Type physically assaulted another resident in the dining room. The aggressor lifted the victim from a chair and pushed them to the ground, although no injuries were reported. The facility's administrator confirmed the details of the altercation, noting the aggressor's potential delusional state. The facility's policy on abuse prevention, updated shortly before these incidents, emphasizes the residents' right to be free from abuse and outlines the types of abuse, including physical abuse, which involves inflicting injury that requires medical attention. Despite this policy, the facility did not prevent the physical altercations between residents, resulting in a failure to protect them from abuse. The incidents were documented in the facility's incident investigation reports, and the police were notified in the second case. However, the facility's actions were insufficient to prevent these occurrences, highlighting a deficiency in protecting residents from abuse by other residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 155 citations issued within 25 miles in the last 12 months — including the 9 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 mi | ★★★★★ | 10 | 1 |
| 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.