Sharmar Village Senior Care Community

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

A survey prompted by complaint #CO1943421 was completed on 8/6/25 to 8/11/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure three (#3, #8 and #11) of six residents reviewed for accidents out of 21 sample residents received adequate supervision to prevent accidents. Resident #3 was admitted to the facility on 3/12/25 with diagnoses of displaced intertrochanteric (upper thigh bone - hip fracture) fracture, acute pain due to trauma and orthostatic hypotension. The resident was known to be a fall risk upon admission due to her fall at home which resulted in the resident’s left hip fracture. However, the fall assessment completed on 3/12/25 documented the resident had not fallen and was a low risk for falls. The facility implemented a fall care plan upon admission which included ensuring items were within the resident’s reach.On 4/18/25 Resident #3 turned her call light on after using the bedside commode in her room. When staff had not responded to the call light after 15 minutes, the resident stood up from the commode and attempted to reach the toilet wipes, which were not within easy reach. The resident sustained a fall which resulted in her transfer to the hospital where she was discovered to have a right wrist fracture and right hip fracture which required surgical repair. Specifically, the facility failed to:-Implement effective fall interventions in order to prevent a fall with major injury to Resident #3;-Ensure fall interventions were consistently implemented for Resident #8; and,-Ensure Resident #11’s foot pedals were in place on her wheelchair when staff were transporting the resident.IV. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on 8/1/25. According to the August 2025 CPO, diagnoses included dementia, history of transient ischemic attack (a brief and temporary interruption of blood flow to the brain) and history of falling.The 8/2/25 nursing admission assessment revealed the resident was confused and had short-term and long-term memory problems. She required assistance from staff for most ADLs and used a wheelchair. The nursing admission assessment..

A complaint survey, prompted by #CO1943423, #CO1943426, #CO2573565, #CO2579283, #CO2581702, Incident #2564193 and Incident #2564212 was conducted on 8/6/25 to 8/11/25. Six deficiencies were cited. Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#8) of two residents out of 21 sample residents. Specifically, the facility failed to ensure nursing staff followed the physician ordered pain parameters when administering as needed (PRN) pain medication to Resident #8.Findings include:I. Facility policy and procedureThe Pain Management policy, dated 2025, was provided by the nursing home administrat.. Based on observations, interviews, and record review, the facility failed to ensure that four (#1, #14, #7 and #2 of seven residents reviewed for activities received an ongoing program of activities designed to meet needs and interests, and promote physical, medical, and psychosocial well-being out of 21 sample residents. Specifically, the facility failed to offer and provide a personalized activity program for four Residents (#1, #14, #7 and #2). IV. Resident #21.Resident statusResident #2, age greater than 65, was admitted on 5/15/24. According to the August 2025 CPO, d.. Based on observations, record review and interviews, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and quality of life in the facility that were important to the residents.Specifically, the facility failed to ensure resident council grievances were addressed to resolve resident concerns related to call light response times.Findings include:I. Facility policyThe Grievance policy, dated September 2016, was received from the nursing home administrator (NHA) on 8/11/25 at 4:1.. Based on observations, record review and interviews, the facility failed to ensure menus met the resident' s nutritional needs.Specifically, the facility failed to ensure residents were provided adequate food to ensure they were not hungry after meals and in between meals. Findings include:I. Facility policy and procedure The Menu Planning and Requirements policy, dated 2020, was provided by the nursing home administrator (NHA) on 8/11/25 at 12:33 p.m. It revealed in pertinent part, “Menus are planned to provide nourishing, palatable, attractive meals that meet the nutr.. Based on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#9 and #16) of the three residents reviewed for oxygen use out of 21 sample residents.Specifically, the facility failed to:-Ensure Resident #9 and #16 did not run out of oxygen in their portable oxygen tanks; and,-Ensure staff used the appropriate personal protective equipment (PPE) when filling residents’ portable oxygen tanks.II. Resident #16A. Resident statusResident #16, age 71, was admitted on 3/12/18 and readmitt.. Based on observations, record review and interviews, the facility failed to ensure three (#3, #8 and #11) of six residents reviewed for accidents out of 21 sample residents received adequate supervision to prevent accidents. Resident #3 was admitted to the facility on 3/12/25 with diagnoses of displaced intertrochanteric (upper thigh bone - hip fracture) fracture, acute pain due to trauma and orthostatic hypotension. The resident was known to be a fall risk upon admission due to her fall at home which resulted in the resident’s left hip fracture. However, the fall assessme..

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.Rm#7 Do not stop the passage of smoke (door gap)2.Rm#29 Do not stop the passage of smoke (does not latch)NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the 2 of 4 Smoke Compartments. Deficient items were discussed with the maintenance director and administrator at the exit conference. The facility is one story, Type V (000), wood framed structure. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler systems. The facility ' s fire sprinkler system is a wet pipe system that contains an anti-freeze loop with a propylene glycol solution and protects the front and back porch only. The facility was constructed in 1989. Also located on the property is an Assisted Living Facility that is separated from the Long Term Care Facility by a two-hour fire rated wall. The 59 bed facility was surveyed on March 10, 2025 using the National Fire Protection Association, (NFPA) Life Safety Code (2012) chapter 19, Existing Health Care Occupancies. An exit conference was conducted with the Executive Director and Physical Plant Manager at the end on-site survey.