Sharon Health Care Elms

In the surveyor’s words

From the most serious findings on record at Sharon Health Care Elms, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 22, 2025

  Based on interview and record review the facility failed to ensure that a resident received adequate supervision and dietary management to prevent a choking incident for one of three residents (R2) reviewed for choking in the sample of six. These failures resulted in the resident (R2) consuming food inconsistent with his prescribed mechanical soft diet, leading to a fatal choking event at the facility.These failures resulted in an Immediate Jeopardy that began on 7/23/25. While the Immediate Jeopardy was removed on 12/17/25, the facility remains out of compliance at a severity level two. […]

• Immediate jeopardy, isolatedF689Aug 2, 2021

  Based on observation, interview and record review, the facility failed to provide supervision for a resident identified as a high risk for falls and implement and follow fall interventions for two residents of (R5, R43) of four reviewed for falls in a sample of 35. This failure resulted in R43 experiencing an unwitnessed fall, subsequently sustaining a Subarachnoid hemorrhage and a well-circumscribed compression deformity of the anterior superior C7 vertebral endplate requiring hospitalization . These failures resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF600May 31, 2025

  Based on observation, interview, and record review the facility failed to adequately supervise a resident (R1) to prevent resident-to-resident physical abuse for five of five residents (R1-R5) reviewed for abuse in the sample of five. These failures resulted in R1 punching R2 in the left eye, causing a hematoma under R2's left eye and bruising surrounding R2's left eye, and R1 punching R5 in the right arm, causing R5 right arm pain for three days. Findings include: The facility's Abuse Prevention Program policy undated documents, Policy: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. […]

• Actual harm, isolatedF689Apr 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure resident safety after a transfer and failed to keep a resident free from injury for one of three residents (R1) reviewed for accidents/injuries in a sample of four. This failure resulted in R1 sustaining pain, bruising and a hospital visit with fractures to the left ankle and foot. Findings include: The facility's undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to safety: The facility must provide services to keep your physical and mental health, at their highest practical levels. The facility's Resident Accident/Incident Policy, revised 5/12/15, documents It is the Policy of (named facility) to provide a safe environment for all residents. […]

• Actual harm, isolatedF689Feb 10, 2025

  Based on observation, interview, and record review, the facility failed to transfer a resident with the required mechanical lift, for one of three residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1 falling twice and during the second fall sustaining a periprosthetic distal left femur fracture, ongoing pain, and psychosocial fear of being transferred with a mechanical lift. FINDINGS INCLUDE: The facility policy, Fall Policy and Procedure directs staff, It is the policy of (the facility) to provide an environment conducive to reducing risk for falls. […]