Inspection Reports for
Sharon Care Center

The facility failed to ensure adequate nutritional care for a resident at risk for dehydration and malnutrition by not fully implementing physician orders for a Restorative Nursing Aide feeding program. This failure resulted in unplanned severe weight loss and placed the resident at risk for further decline.

The facility failed to ensure that Resident 1, who was at risk for dehydration and malnutrition, received the ordered restorative nursing aide feeding program at both breakfast and lunch, resulting in unplanned severe weight loss of 9.4% over three months. This failure placed the resident at risk for further decline and complications related to protein-calorie malnutrition.

The complaint investigation focused on Resident 1, who was refusing to eat and care, resulting in severe dehydration, sacral pressure ulcer deterioration, and hospitalization. The investigation substantiated failures in reporting, care planning, order implementation, and pressure ulcer management. Resident 1 ultimately expired on 11/15/2025.

The facility failed to notify the physician and family about Resident 1's declining condition and refusal of care, failed to develop a comprehensive care plan including the interdisciplinary team and family, failed to carry out physician orders for labs and IV fluids, and failed to provide adequate pressure ulcer care and hygiene. These deficiencies contributed to Resident 1's severe dehydration, deterioration of a sacral pressure ulcer, hospitalization, and eventual death.

The complaint investigation focused on Resident 1, who was refusing to eat and had a deteriorating sacral pressure ulcer. The facility failed to notify the physician and family about the change in condition, failed to implement physician orders, and failed to conduct proper care planning. Resident 1 was transferred to hospital with severe complications and expired on 11/15/2025.

The facility failed to notify the physician and family about Resident 1's declining condition, failed to carry out physician orders including IV fluids and lab tests, failed to conduct interdisciplinary team meetings including the resident or representative, and failed to prevent deterioration of pressure ulcers. These deficiencies contributed to Resident 1's severe dehydration, infection, and eventual death.

The facility failed to update care plans for residents after significant changes in condition, including failure to revise care plans for urinary catheter management and COPD monitoring. Additionally, the facility failed to ensure proper disposal and labeling of feeding tube supplies, placing residents at risk for infection and other complications.

The facility failed to revise care plans for residents after significant changes in their conditions, including failure to update care plans after urinary catheter removal and reinsertion, failure to update care plans after hospital readmission for respiratory failure, and failure to properly dispose of and label feeding tube supplies. These deficiencies placed residents at risk for urinary retention, infection, sepsis, aspiration, and inadequate management of respiratory status.

The facility failed to provide adequate pain management for Resident 2 by not notifying the physician when the resident continued to experience pain after medication and requested more frequent dosing. This resulted in the resident remaining in pain and discomfort while waiting for the scheduled medication interval.

The complaint was substantiated based on observations, interviews, and record reviews showing deficient pain management practices for Resident 2.

The facility failed to manage pain effectively for Resident 2 by not notifying the physician when the resident continued to experience pain after medication and requested more frequent dosing. This resulted in the resident remaining uncomfortable and waiting longer than appropriate for pain relief.

The facility failed to arrange transportation in advance for a resident's chemotherapy appointment, resulting in transportation being booked only on the day of the appointment. This failure had the potential to cause the resident to miss the chemotherapy treatment.

The facility failed to assist and make transportation arrangements for recurring chemotherapy appointments for one sampled resident, which had the potential to result in the resident missing treatment. The facility acknowledged that transportation was not booked until the day of the appointment, contrary to policy.

The facility had multiple deficiencies including failure to ensure proper medication administration, inadequate care planning, unsafe environmental conditions, improper pressure ulcer care, unsafe medication storage, infection control lapses, and nonfunctional call light systems.

The facility was found deficient in multiple areas including medication administration without proper orders, failure to provide warm water for resident preferences, inadequate care planning for hearing impairment, improper pressure ulcer prevention measures, unsafe environmental hazards, failure to notify physicians of catheter sediment, unlabeled feeding tube syringes, lack of emergency dialysis kits, improper medication storage, food safety violations, infection control lapses, inadequate room space for residents, and malfunctioning call light systems.

The complaint investigation found that Resident 3's PRN Seroquel orders did not have the required 14-day stop date. The psychiatrist confirmed she did not order the PRN medication and typically discontinues such orders. The Director of Nursing and Pharmacy Consultant agreed the PRN order should have a 14-day stop. The facility policy requires PRN psychotropic orders to be limited to 14 days unless documented otherwise.

The facility failed to ensure Resident 3's PRN psychotropic medication orders had a required 14-day stop date, resulting in an increased risk to the resident's mental and psychosocial well-being. Interviews and record reviews confirmed that the PRN orders for Seroquel lacked the 14-day limit and were not properly discontinued.

The facility failed to ensure that one sampled resident's (Resident 3) PRN psychotropic medication order had a documented 14-day stop date, resulting in an increased risk to the resident's mental and psychosocial well-being. Interviews and record reviews confirmed that the PRN Seroquel orders lacked the required 14-day limit and were not discontinued as per facility policy.

The complaint investigation focused on Resident 1's mental health assessments and care. The PASARR Level I screening was incomplete, and the facility did not complete the required Level II assessment. The facility also failed to notify the physician after significant changes in Resident 1's condition and did not update care plans accordingly. These failures contributed to Resident 1's behavioral escalation and hospitalization.

The facility failed to complete a required PASARR Level II assessment for Resident 1, resulting in inadequate mental health follow-up. Additionally, the facility did not notify the physician after significant changes in Resident 1's condition, failed to update care plans after changes in behavior, and lacked specific interventions for medication monitoring, leading to escalation of behaviors and hospitalization.

The complaint investigation focused on Resident 1, who had diagnoses including schizophrenia and mood disorder. The facility failed to complete PASARR Level II screening, notify the physician after significant behavioral changes, and update the care plan accordingly. Resident 1 exhibited verbal aggression and agitation, resulting in a 5150 psychiatric hold and transfer to General Acute Care Hospital (GACH). The Director of Nursing and other staff acknowledged these failures during interviews.

The facility failed to ensure accurate PASARR screening and follow-up for Resident 1, did not notify a physician after a significant change in Resident 1's mental and physical condition, and failed to update and implement a comprehensive care plan addressing Resident 1's behavioral symptoms and medication interventions. These deficiencies contributed to Resident 1's behavioral escalation and hospitalization.

The facility was found deficient in developing and implementing comprehensive care plans for residents, specifically for pain management and fracture care. Additionally, the facility failed to ensure proper assessment and monitoring of a resident's leg splint, provide sufficient nursing staff to meet resident needs, and deliver scheduled showers to residents as required.

The complaint investigation found substantiated deficiencies related to care planning, pressure ulcer prevention, and staffing adequacy affecting multiple residents.

The facility failed to develop and implement baseline care plans for pain management and fracture care for Resident 1, did not ensure proper assessment and monitoring of Resident 1's left lower leg splint, and failed to provide sufficient nursing staff to assist residents with basic care and scheduled showers, affecting Residents 1, 4, and 5.

The investigation was complaint-driven, focusing on the facility's failure to respond appropriately to critical lab results for Resident 1. The complaint was substantiated as the facility delayed emergency transfer and physician notification.

The facility failed to ensure nurses recognized and acted promptly on critically low platelet counts for Resident 1, resulting in delayed transfer to acute care and increased risk of bleeding. The physician was not immediately informed of critical lab results, contributing to Resident 1's death seven days later.

The complaint investigation found that the facility did not promptly notify the physician or transfer Resident 1 emergently despite critically low platelet counts, resulting in delayed hospital transfer and increased risk of bleeding. Resident 1 died seven days later at the hospital.

The facility failed to ensure timely recognition and communication of critically low platelet counts for Resident 1, resulting in delayed transfer to a hospital and increased risk of spontaneous bleeding. Interviews with nursing staff and the Director of Nursing revealed lapses in following emergency protocols and notification procedures. The resident subsequently died seven days after transfer.

The facility failed to honor food preferences for two residents by providing only canned fruits instead of fresh fruits. Additionally, the facility did not ensure that dinnerware and food service equipment were clean and in good condition, including stained cups, worn coffee pot lids, and improperly changed water pitchers.

The facility failed to honor food preferences for two residents by providing only canned fruits instead of fresh fruits. Additionally, the facility did not ensure that dinnerware and food service equipment were clean and in good condition, including stained cups, worn coffee pot lids, and improperly changed water pitchers.

The facility was found deficient in developing and implementing comprehensive care plans for residents, ensuring employee performance evaluations and competency checklists were completed, and obtaining documented consent for psychotropic medications. These deficiencies posed minimal harm or potential for actual harm to residents.

The facility failed to develop a comprehensive care plan for a resident with bipolar disorder and psychotropic medication, lacked yearly performance evaluations for a licensed vocational nurse, did not maintain a yearly skills competency checklist for a certified nurse assistant, and failed to obtain documented consent for psychotropic medications for the resident. These deficiencies posed minimal harm or potential for actual harm to a few residents.

The complaint involved a resident-to-resident abuse incident between Resident 1 and Resident 7. The incident was not reported to authorities, not investigated, and residents were not separated timely. The facility administrator did not report the incident because there was no injury and it was considered just an argument.

The facility failed to follow its abuse policy and procedures for two residents involved in a resident-to-resident abuse incident. The incident was not reported to the state licensing office, police, or ombudsman, was not investigated, and the residents were not separated in a timely manner.

The complaint investigation focused on an incident between Resident 1 and Resident 7 involving resident-to-resident abuse. The facility failed to report the incident to the state licensing/certification office, police, and ombudsman, did not investigate the incident, and did not separate the residents promptly. Both residents initially refused room changes. The facility administrator did not report the incident, considering it only an argument without injury.

The facility failed to timely report a resident-to-resident abuse incident to the state licensing office, police, and ombudsman, did not investigate the incident, and did not separate the residents in a timely manner. The incident involved two residents arguing and attempting to strike each other, with delayed room changes and no official reporting or investigation.

The complaint investigation found that Resident 2 was mistakenly transported to a skilled nursing facility instead of an ophthalmologist appointment due to misidentification. Resident 2 was upset and missed the appointment. Additionally, Resident 1 had a fall during the night shift on 10/16/24, but the fall was not documented immediately, and the physician was not notified promptly.

The facility failed to ensure correct resident identification resulting in a resident being transported to the wrong location and missing a medical appointment. Additionally, the facility failed to assess a resident immediately after a fall and notify the physician and responsible party in a timely manner.

The complaint investigation found that Resident 2 was mistakenly transported to a skilled nursing facility instead of an ophthalmologist appointment due to confusion over residents with the same first name. Resident 2 missed the appointment and was upset. Additionally, Resident 1 had a fall during the night shift that was not documented immediately, and the physician was not notified promptly.

The facility failed to ensure correct resident identification during transportation, resulting in Resident 2 being taken to the wrong location and missing an ophthalmologist appointment. Additionally, the facility failed to assess Resident 1 immediately after a fall and did not notify the physician or responsible party promptly.

The facility failed to ensure quarterly Braden scale assessments for a resident with pressure ulcers and did not develop or revise care plans appropriately for the resident's wounds, including a Stage IV pressure ulcer and vascular wounds. These deficiencies increased the risk of worsening skin integrity and delayed healing.

The facility failed to ensure that one sampled resident with pressure ulcers had quarterly Braden scale assessments completed and that care plans were properly developed and revised to reflect changes in wound status. This included failure to develop a care plan for a new vascular wound and failure to revise the care plan when a pressure ulcer was reclassified to Stage IV. These deficiencies posed an increased risk of worsening skin integrity and delayed healing.

The complaint investigation substantiated that CNA 1 verbally abused Resident 1 by using derogatory language on 8/12/2024. Resident 1 and Resident 2 both reported hearing the derogatory word. CNA 1 admitted to responding with the derogatory term after being called the same by Resident 1. The Director of Nursing and Administrator confirmed the inappropriate use of language violated facility policy.

The facility failed to protect Resident 1 from verbal abuse when CNA 1 used a derogatory word during a conversation about the resident's socks. Multiple interviews and observations confirmed the use of inappropriate language by CNA 1, constituting verbal abuse with potential mental anguish to Resident 1.

The complaint investigation was substantiated based on interviews, observations, and record reviews confirming verbal abuse by CNA 1 toward Resident 1 on 8/12/2024. The Director of Nursing and Administrator acknowledged the inappropriate communication and reviewed facility policies on abuse prohibition.

The facility failed to protect Resident 1 from verbal abuse when CNA 1 used a derogatory word during an interaction about the resident's socks. Multiple interviews and observations confirmed the use of inappropriate language by CNA 1, which caused Resident 1 mental anguish. The facility's policies prohibit such verbal abuse and require effective communication.

The complaint investigation substantiated that Resident 2 was incorrectly billed for a single room while another resident was on bed hold in the same room. It also found delays in implementing dietitian recommendations for Resident 1's G-tube feeding and failures in care planning and interdisciplinary team meetings related to G-tube dislodgements.

The facility failed to ensure Resident 2 was not billed for a single room while another resident was on bed hold in the same room. The facility also delayed following dietitian recommendations for Resident 1's G-tube feeding formula for 51 days, resulting in weight loss. Additionally, the facility did not develop timely care plans or conduct interdisciplinary team meetings after multiple G-tube dislodgements for Resident 1.

The facility failed to ensure proper billing for a single room when another resident was on bed hold, delayed following dietitian recommendations for gastrostomy feeding formula changes resulting in weight loss, and did not develop or timely revise care plans and interdisciplinary team meetings for feeding tube dislodgements, leading to multiple replacements.

The facility was found deficient in multiple areas including failure to provide required notices to residents regarding Medicare coverage, inadequate follow-up on missing resident property, failure to notify the Ombudsman of resident transfers, lack of care plans for medications, delays in physician consultations, failure to follow medication orders, inadequate fall prevention measures, failure to monitor and address severe weight loss, incomplete staff competency evaluations, lack of informed consent for psychotropic medications, failure to rotate insulin injection sites, expired medication storage, unsanitary food storage conditions, incomplete hospice documentation, insufficient resident room space, and call light accessibility issues.

The facility had multiple deficiencies including failure to provide required Medicare notices, missing follow-up on resident personal items, incomplete care plans, delayed physician orders, medication errors, unsanitary food storage, incomplete hospice documentation, inadequate room space, and call light accessibility issues.

The facility failed to ensure one resident received treatment and care according to physician's orders by not applying bilateral compression sleeves and stockings as ordered. This failure had the potential to cause swelling, pain, decreased blood flow, and tissue death.

The visit was complaint-related, focusing on substantiation of failure to provide ordered compression therapy for Resident 1. The deficiency was substantiated with observations and record review confirming non-compliance with physician orders.

The facility failed to ensure that Resident 1 received ordered bilateral compression sleeves and stockings for lymphedema management, resulting in potential harm including swelling, pain, decreased blood flow, and tissue death. Observations showed inconsistent use of compression devices despite physician orders, and the Director of Nursing confirmed the orders and the requirement to notify the doctor if the resident could not tolerate the devices.

The facility failed to remove discontinued gabapentin 300 mg from the medication cart for one resident, which posed a potential risk for medication errors. Interviews and record reviews confirmed the presence of discontinued medication and identified gaps in medication disposal procedures.

The facility failed to remove discontinued gabapentin 300 mg medication from the medication cart for one resident, which posed a potential medication error risk. Interviews and record reviews confirmed the presence of the discontinued medication and the need for its removal according to facility policy.

The complaint investigation was substantiated. The facility did not report the physical altercation between Resident 1 and Resident 2 to the local California Department of Public Health within the required two hours, as confirmed by interviews with staff and the Administrator.

The facility failed to report a physical altercation between Resident 1 and Resident 2 within two hours as required by state regulations, resulting in a delayed onsite inspection by the Department of Public Health and potential increased risk to the residents. Both residents had no injuries from the incident, and the facility's policy requires reporting allegations of abuse within two hours.

The complaint investigation found that the facility did not report the physical altercation between Resident 1 and Resident 2 within the required two hours to the local California Department of Public Health. The report was faxed the following morning, resulting in a delay of the investigation. The complaint was substantiated based on interviews and record reviews.

The facility failed to report the physical altercation involving two residents to the local California Department of Public Health within the required two-hour timeframe, resulting in a delayed onsite inspection and potential increased risk to the residents.

The facility failed to maintain proper infection control by not ensuring staff wore masks during a COVID-19 outbreak. It also failed to offer or document influenza and COVID-19 vaccinations for multiple sampled residents, resulting in increased risk and actual COVID-19 infections among residents.

The facility failed to ensure staff wore masks during a COVID-19 outbreak, failed to offer influenza vaccination to two of six sampled residents, and failed to offer or document COVID-19 vaccination for six sampled residents, resulting in COVID-19 infections among those residents.

The complaint involved Resident 1's report that the facility failed to timely provide acetaminophen for headache and that a nurse was loud and disrespectful. The complaint was substantiated based on interviews, record reviews, and staff statements.

The facility failed to assess and administer acetaminophen to Resident 1 in a timely manner on 11/7/2023 and failed to treat the resident respectfully when she requested the nurse to lower her voice. These deficiencies caused distress to Resident 1.

The complaint was substantiated based on interviews and record reviews indicating the facility's failure to timely administer medication and treat Resident 1 respectfully, including LVN 1's loud voice and delayed medication administration.

The facility failed to assess and administer acetaminophen to Resident 1 in a timely manner on 11/7/2023, and a Licensed Vocational Nurse (LVN 1) went on a meal/rest break before giving the medication. Additionally, LVN 1 did not lower her voice when requested by Resident 1, resulting in the resident feeling disrespected and upset.

The visit was complaint-related, focusing on allegations of failure to provide psychosocial follow-up after abuse, failure to arrange home health services upon discharge, and failure to conduct required interdisciplinary team meetings. The deficiencies were substantiated with evidence from interviews and record reviews.

The facility failed to provide psychosocial follow-up for Resident 1 after an alleged abuse incident, failed to arrange home health services for Resident 3 upon discharge, and failed to conduct an interdisciplinary team meeting for Resident 3 within 72 hours of admission. These deficiencies had the potential to negatively impact resident care and safety.

The investigation was complaint-driven, focusing on psychosocial follow-up after abuse, discharge planning, and care plan development. The deficiencies were substantiated with evidence from interviews and record reviews.

The facility failed to provide psychosocial follow-up for Resident 1 after an alleged abuse incident, failed to arrange home health services for Resident 3 upon discharge, and failed to conduct an interdisciplinary team meeting for Resident 3 within 72 hours of admission, potentially compromising resident care and safety.

The complaint investigation was substantiated. Resident 1 reported being restrained and catheterized without consent on 7/6/2023, resulting in trauma, pain, and emotional distress. The facility suspended involved staff, conducted investigations, and implemented corrective actions including education and psychological support for Resident 1.

The facility failed to protect Resident 1 from physical and mental abuse by three employees who restrained her and performed straight catheterization without her consent, causing pain and emotional distress. Additionally, the facility failed to obtain physician orders for straight catheter urine collection for Residents 1, 2, and 3, violating professional standards of care.

The facility failed to protect Resident 1 from physical and mental abuse during a straight catheter urine collection without consent, resulting in immediate jeopardy. Additionally, the facility failed to obtain physician orders for straight catheter urine collection for three residents, and failed to update Resident 1's care plan to reflect accurate advance directive status.

The visit was complaint-related, focusing on whether the resident's representative was included in care planning. The complaint was substantiated as the representative was not included in IDT meetings from 1/2023 to 7/2023.

The facility failed to include the resident's representative in the IDT meetings for one of three sampled residents, which potentially compromised meeting the resident's needs. Interviews and record reviews confirmed that the resident's representative was not involved in care planning from January to July 2023, contrary to the facility's policy encouraging family participation.

The complaint investigation found that the resident's representative was not included in IDT meetings from January 2023 to July 2023. The facility acknowledged this omission and confirmed that the representative should have been contacted and involved in care planning.

The facility failed to ensure that the comprehensive individualized care plan was prepared by an interdisciplinary team that included the resident's representative for one of three sampled residents. The resident's representative was not included in IDT meetings from January to July 2023, contrary to facility policy.

The complaint investigation found substantiated failures in diabetes management and emergency response, including lack of blood sugar reassessment after insulin administration and delayed CPR initiation leading to resident death.

The facility failed to reassess a resident's blood sugar after administering insulin, potentially leading to ineffective diabetes management. Additionally, the facility staff delayed initiating CPR when the resident was found unresponsive on the floor, contrary to facility policies, which contributed to the resident's death.

The complaint investigation focused on Resident 1's care related to blood sugar management and emergency response. The findings substantiated failures in blood sugar reassessment and emergency CPR response, contributing to Resident 1's death.

The facility failed to reassess Resident 1's blood sugar after administering insulin as ordered, lacked policies on hyperglycemia management, and delayed CPR initiation after Resident 1 was found unresponsive on the floor, resulting in the resident's death.

The facility failed to conduct required interdisciplinary team meetings for Resident 1 since admission and failed to ensure monthly physician face-to-face visits from January 2023 to June 5, 2023. These deficiencies had the potential to delay necessary care and result in missed or delayed treatment.

The facility failed to conduct interdisciplinary team meetings for one sampled resident and did not ensure monthly physician face-to-face visits from January 2023 to June 5, 2023. These deficiencies had the potential to delay necessary care and result in missed or delayed treatment.

The complaint was substantiated as the facility failed to provide requested medical records to Resident 1's Power of Attorney within the required timeframe.

The facility failed to provide requested medical records to Resident 1's Power of Attorney in accordance with the facility's policy and procedures. The Director of Nursing confirmed the delay in providing access to the records despite the legal right to obtain them.

The facility failed to provide a copy of medical records upon written request for one of three sampled residents, violating the resident's legal right to access their records. The deficiency was related to delays in providing access to protected health information as required by federal and state regulations.

The complaint was substantiated based on Resident 1's report, a witness statement from Resident 2 (roommate), and the facility's investigation. CNA 1 denied the allegation but resigned before the investigation concluded.

The facility substantiated the allegation that CNA 1 called Resident 1 'stupid' on 4/3/2023, constituting verbal abuse. Resident 1 was psychologically affected, and the CNA resigned before the investigation was completed.

The complaint was substantiated based on Resident 1's report and confirmation by Resident 2, the roommate and witness. CNA 1 denied the allegation but resigned before the investigation was completed.

The facility substantiated the allegation that CNA 1 called Resident 1 'stupid' during a night shift, which constituted verbal abuse. Resident 1 was cognitively impaired but alert and oriented, and the incident was witnessed by Resident 2. CNA 1 resigned before the investigation was completed.

The investigation was complaint-driven, focusing on Resident 1's care related to gastrostomy tube dislodgements and delayed IV fluid administration. The complaint was substantiated with findings of deficient care planning and communication.

The facility failed to develop a specific care plan for Resident 1's multiple gastrostomy tube dislodgements and did not notify the physician that Resident 1 had not received IV fluids for 12 hours. These deficiencies resulted in multiple hospital visits and posed risks of dehydration and low blood sugar.

The facility failed to develop a specific care plan for Resident 1's repeated G-Tube dislodgements and did not notify the physician that Resident 1 had not received IV fluids for 12 hours as ordered. These deficiencies resulted in multiple hospital visits and potential harm due to dehydration and low blood sugar.

The complaint involved allegations that a Certified Nursing Assistant refused to give Resident 1 snacks and made verbal remarks about the resident's weight. The facility did not report the abuse allegation to the Department of Public Health as required.

The facility failed to protect Resident 1 from mental and verbal abuse by a Certified Nursing Assistant, resulting in the resident feeling uncomfortable. Additionally, the facility failed to timely report the alleged abuse to the Department of Public Health, preventing a proper investigation.

The complaint involved allegations that CNA 1 refused to give Resident 1 snacks brought by family and made comments about Resident 1 being 'too fat.' The allegation was reported by Resident 1 to CNA 2, who informed LVN 1. The facility failed to notify the abuse coordinator and did not report the allegation to the Department of Public Health in a timely manner.

The facility failed to protect Resident 1 from mental and verbal abuse by CNA 1, resulting in the resident feeling uncomfortable. Additionally, the facility failed to timely report the alleged abuse to the Department of Public Health, resulting in Resident 1 not receiving a proper investigation.

The facility failed to maintain a belongings inventory list for one resident, resulting in inability to account for the resident's belongings. Additionally, the facility failed to provide the Restorative Nursing Assistant program for one resident for 39 days in 2020, increasing risk of mobility and range of motion decline.

The facility failed to maintain a belongings inventory list for one sampled resident, resulting in potential psychological harm. Additionally, the facility failed to provide the RNA program for Resident 1 for multiple days across several months in 2020, increasing the risk of mobility and range of motion decline.

The facility was found deficient in multiple areas including resident dignity and rights, medication administration, infection control, staffing levels, care planning, food safety, and safety precautions. Specific issues included failure to provide adequate assistance during showers, improper medication documentation, inadequate infection prevention practices, insufficient staffing, and failure to maintain safe environments.

The facility was found deficient in multiple areas including resident dignity and privacy, medication self-administration, call light accessibility and response, infection control practices, staff competency and identification, medication administration documentation, resident care planning, supervision to prevent accidents, food safety and preparation, staffing levels, and COVID-19 vaccination and screening protocols.