CareOne at Sharon

• Service and Service Coordination Requirements-

Self-Administered Medication Management (SAMM)

• AGE reviewed nine Resident Records to determine compliance with requirements for Self-administered Medication Management (SAMM).
• Documentation of actions regarding whether the Resident took or refused the medication on multiple dates and times was missing for seven Residents.

Emergency Response

• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• During the months of December 2023, April 2024 and June 2025, there were 1,069 e-call response times over the 15-minute limit.

Dietary Reviews

• EOEA reviewed the Residence's dietary plan reviews from September 2023 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
• Some menus lacked the inclusion of the required language designating that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
• Service and Service Coordination- Special Care
• AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the Residence is complying with all the required safeguards.
• Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
• E-call pull cord in the SCR kitchen was wrapped around the call box.
• Unsecured microwave in the SCR kitchen.
• Multiple SCR window's tilt-in function was not disabled.
• General Requirements for an Assisted Living Residence (ALR)
• AGE reviewed the documentation of eight Resident Records from September 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Screening and Assessment

• Six records were missing documentation of an initial assessment being completed by a nurse.
• Two records were without documentation to confirm that assessments noted the name and scope of any Legal Representative.

Service Plan Development and Requirements

• Five SCR records were missing documentation that Residents have supervised access to a heating element.
• Two records were missing documentation of Resident goals.
• Eight records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Documentation of a service plan review required every six months or after a change in Resident condition, was missing for seven records.

Bed Rail Assessments

• AGE reviewed the Residence records of 34 Residents utilizing bed rails / U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Two records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar.
• Quality Assurance and Performance Improvement
• AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from September 6, 2023, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was completed was missing for the 2024 calendar year reviewed.

Resident Safety Assurances

• Documentation of the date the audit was completed was missing for the 2024 and 2025 calendar years reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from September 6, 2023, through the date of the Compliance Review to ensure compliance with SAMM , LMA and Residence policies.
• Documentation of clear findings was missing for the last three quarters of 2024 calendar year reviewed.
• Documentation of the target date for follow-up action was missing for the first two quarters of 2025 calendar year reviewed.
• Documentation of the staff person responsible for follow-up was missing for the last quarter of 2023 and the first two quarters of the 2025 calendar year reviewed.
• Documentation of clear outcomes was missing for the first quarter of the 2025 calendar year reviewed.

Medication administration observation

• AGE observed one Personal Care (PC) staff and one nurse providing medication assistance to nine Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

SAMM

• AGE observed several over the counter medications in two Resident's medication storage units.
• AGE observed an unopened medication blister scheduled on a previous date in two Resident's medication storage units.
• AGE observed a Exemption C without a box labeled with the open date in one Resident's medication storage unit.
• AGE observed a bag of unused bottled medications in one Resident's medication storage cabinet.
• AGE observed an expired medication in one Resident's medication storage unit.
• AGE observed medications belonging to Exemption C who is
• Exemption C unsecured in Residents' unit.

LMA

• AGE observed two expired medications, one discontinued medication, and two medications without proper label documentation in one Resident's medication storage unit.
• Emergency Preparedness Plan and Reporting Requirements-Evacuation Drills and Rehearsals
• AGE reviewed the Residence's Emergency Plan to ensure compliance that the
• Residence can address potential disasters and emergencies.
• Documentation of an elopement drill was missing for the third shift during 2023 and the second and third shift for the 2024 calendar year reviewed.
• Documentation of fire drills was missing for third shift for the 2023 calendar year reviewed.

Reporting Resident-specific Emergencies- Incident Reports

• AGE reviewed the Residence records and incident reports from September 6, 2023 through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.
• The Residence filed 40 incident reports greater than 24 hours after the occurrence of an incident or accident.
• Record Requirements- Correspondence Log
• AGE reviewed all current Correspondence Logs required to communicate information necessary to maintain the continuity of care for all Residents.
• The SCR and Traditional logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• Staffing Requirements- Health Screening Requirements
• AGE reviewed the personnel records of nine staff members to determine compliance with Health Screening requirements.
• Six records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.
• Training Requirements-

Introductory Visit and Review

• AGE reviewed the records of nine Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident:
• Nine records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.

Supervision

• AGE reviewed the records of five Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2023 through the date of the Compliance Review.
• Documentation confirming the completion of SAMM and skills evaluations every six months was missing from five records for the 2024 calendar year reviewed.
• Training Requirements- LBGTQ Training
• AGE reviewed nine personnel records to determine compliance with training requirements.
• Two (2) records were missing documentation to confirm completion of required LGBTQ training.