Inspection Reports for
CareOne at Sharon

Medication assistance, Emergency call response, Food and dietary services: Documentation of actions regarding whether the Resident took or refused medication was missing for seven Residents. During December 2023, April 2024 and June 2025, there were 1,069 emergency call response times over the 15-minute limit. Some menus lacked the required nutrition-standards statement (repeat finding).

Memory care unit: Physical hazards were identified including an e-call pull cord wrapped around the call box, an unsecured microwave, and multiple windows with tilt-in function not disabled.

Resident screening and assessment, Resident care plans: Six records were missing documentation of an initial nurse assessment, two lacked documentation of Legal Representative details, five SCR records lacked documentation of supervised heating element access, two lacked Resident goals, eight lacked service plan review within 30 days of residency start, seven lacked six-month or change-of-condition service plan reviews, and two records lacked current bed rail assessments (repeat finding).

Quality assurance program: Documentation of audit dates was missing for 2024 and 2025 calendar years. Medication documentation audits lacked clear findings and target dates for follow-up action. Observations included over the counter medications, unopened and expired medications, and medications without proper labeling, including some belonging to [redacted] unsecured in Residents’ unit (repeat finding).

Emergency drills, Incident reporting: Documentation of elopement and fire drills was missing for various shifts in 2023 and 2024. The Residence filed 40 incident reports more than 24 hours late (repeat finding).

Resident records: Correspondence Logs did not consistently document all significant information necessary for continuity of care (repeat finding).

Staff health screening: Six personnel records were missing documentation confirming seasonal influenza vaccinations or declination statements for the 2024/2025 flu season (repeat finding).

Staff training: Nine records lacked documentation supporting consistent Introductory Visits with staff. Five Personal Care staff records lacked documentation of biannual SAMM and skills evaluations for 2024 (repeat finding).

Staff training: Two personnel records were missing documentation confirming completion of required LGBTQ training.