Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sharon Care Center during CMS and state inspections, most recent first.
Two residents who required staff assistance for toileting were not checked or changed as scheduled during the night, resulting in one being found with dried BM and another with a saturated brief and bedding. Staff interviews and facility investigations confirmed that the required two-hour check and change protocol was not followed.
Surveyors observed expired and undated food items in both the kitchen and nourishment refrigerators, as well as missing temperature log entries for the nourishment refrigerator on East Hall. Staff interviews confirmed that required procedures for labeling, dating, and monitoring food storage and temperatures were not consistently followed.
A resident with severe cognitive impairment and diagnoses including dementia with agitation and delirium was prescribed Olanzapine, an antipsychotic medication. Facility policy required an AIMS test to be completed upon admission and when starting antipsychotic therapy, but staff interviews and record review confirmed that this assessment was not performed or documented.
A resident's admission MDS assessment was not completed within the required 14-day timeframe. The MDS nurse, responsible for scheduling and completing the assessment, was on vacation and did not finish the assessment on time, leaving it incomplete 16 days after admission. The DON confirmed the expectation for timely completion.
The facility did not complete or submit required PASRR assessments for two residents with mental health diagnoses who remained in the facility beyond the exempted hospital discharge period. Both residents had documentation indicating the need for a Level II evaluation if their stay exceeded 30 days, but no further assessments were conducted or transmitted, as confirmed by the Social Service Director.
A resident with a history of repeated falls did not have their care plan revised to include a new intervention after experiencing a second fall. Although documentation indicated the care plan was updated after the first fall, review showed no new intervention was added following the subsequent incident, and staff interviews confirmed this omission.
The facility did not obtain daily weights as ordered for a resident with heart failure and failed to check for blood return before flushing a PICC line during medication administration for another resident with endocarditis. These actions did not comply with physician orders and were confirmed by staff interviews and record review.
A resident with severe cognitive impairment and chronic pain conditions did not receive required pain assessments every shift, despite care plans and hospice directives mandating regular monitoring. Staff interviews and documentation review confirmed that pain assessments were inconsistently performed, leaving the resident's pain needs unmet.
Sharps containers in two rooms were found filled above the designated line, causing the lids to malfunction and exposing sharps at the opening. Both nursing and environmental services staff stated they would empty the containers if they noticed they were full, but there was no established process or department responsible for monitoring or replacing the containers. This lack of a defined protocol led to the containers being overfilled and observed as a hazard during the survey.
The facility did not include required health recertification and complaint survey results for two years in its publicly accessible survey binder, maintaining only fire and life safety surveys and omitting health-related reports, as confirmed by staff interviews and record review.
The facility failed to assist residents with completing advance directives and maintaining Durable Power of Attorney documentation for four residents. Despite the facility's policy requiring ADs to be reviewed upon admission, the electronic health records for these residents lacked the necessary documentation. Staff acknowledged gaps in documentation and follow-up, which placed residents at risk of not having their healthcare preferences honored.
The facility failed to obtain physician orders for the use of bed rails for two residents, one moderately cognitively impaired and the other alert and oriented. Both residents were observed with quarter length bed rails, but their EHRs lacked the necessary physician orders, as confirmed by staff.
A facility failed to send a Notice Before Transfer to the State Long-Term Care Ombudsman for a resident transferred to a hospital. The resident had diagnoses including congestive heart failure exacerbation. The administrator admitted to not knowing the requirement and sent notices for previous months only after being questioned.
A resident's MDS assessment inaccurately documented their oral/dental status, failing to reflect missing and broken teeth and reported mouth pain. Observations and staff interviews revealed discrepancies between the MDS and the resident's actual condition, highlighting a lack of direct assessment by the MDS Nurse.
A facility failed to develop a comprehensive care plan for a cognitively impaired resident, omitting the placement of the bed against the wall and a mat on the floor. Staff acknowledged the oversight, which was against facility policy, potentially risking the resident's care needs and quality of life.
A facility failed to provide nail care for a resident who was dependent on staff for ADLs. Despite the facility's policy requiring nail care during baths, the resident's nails were not trimmed for about a month. Staff interviews confirmed that nail care was overlooked, and the DON observed that the resident's nails had not been trimmed for about two weeks.
A resident signed an arbitration agreement without a clear understanding due to confusion and lack of proper explanation by facility staff. The staff, including the Admissions Coordinator and Administrator, were unaware of the 30-day rescission period, leading to potential risks for residents signing legal documents without full knowledge.
The facility failed to ensure proper infection prevention practices, including the use of PPE and hand hygiene, for two residents. A CNA did not perform hand hygiene between changing gloves, and two CNAs did not wear isolation gowns when required. Additionally, a CNA used contaminated gloves outside a resident's room. The DON confirmed that staff were expected to follow isolation precaution signs and perform hand hygiene.
Failure to Provide Timely Toileting Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely toileting assistance to two residents who required staff support for activities of daily living. One resident, who was moderately cognitively impaired and dependent on staff for toileting, was found in the morning with dried bowel movement on her sheets and body, and her brief was stuck to her, indicating she had not been checked or changed during the night as required by her care plan. Staff interviews confirmed that the resident was on a two-hour check and change schedule, but this protocol was not followed during the night shift. Another resident, also moderately cognitively impaired and requiring maximum assistance with toileting, reported that her brief was not changed during the night. She was found in the morning with a saturated brief, incontinent pad, and blanket, necessitating a complete bed change. Staff confirmed that this resident was to be checked and changed every two hours, and documentation and interviews indicated that the required care was not provided during the night shift. Both incidents were corroborated by staff and resident interviews, as well as facility investigations.
Failure to Label, Date, and Monitor Food Storage and Temperatures
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in both the kitchen and nourishment refrigerators. During observations, surveyors found expired and undated food items, including a container of Parmesan cheese and a container of jam in the kitchen refrigerator, as well as a fruit cup past its use-by date and six undated fruit cups in the nourishment refrigerator on East Hall. These items were not removed in accordance with the facility's stated policy of discarding food after three days or by the use-by date. Additionally, the facility did not maintain accurate temperature logs for the nourishment refrigerator on East Hall. The temperature log was missing entries for several consecutive days, indicating a lack of consistent monitoring. Staff interviews confirmed that kitchen staff were responsible for labeling, dating, and monitoring food storage and temperatures, but these procedures were not consistently followed, resulting in the deficiencies observed.
Failure to Complete Required AIMS Test for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) test for a resident who was prescribed an antipsychotic medication, Olanzapine, upon admission. According to the facility's policy, an AIMS test should be performed when a resident is admitted on antipsychotic medications, every six months, and as needed. Record review showed that the resident, who had diagnoses including dementia with agitation and delirium and was severely cognitively impaired, was receiving Olanzapine as ordered by the physician. However, there was no documentation of an AIMS test being completed for this resident. Interviews with facility staff, including the Resident Care Manager/RN and the Director of Nursing/RN, confirmed that an AIMS test should have been completed upon admission and when the antipsychotic medication was started. Both staff members acknowledged that the AIMS test was missed for this resident, and it was not found in the resident's electronic health record. This omission was identified during the review of records and staff interviews.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for one resident. According to the Resident Assessment Instrument (RAI) User's Manual, the admission MDS must be completed no later than the 14th calendar day after admission. Record review showed that the resident's admission MDS was still in progress 16 days after admission. During interviews, the MDS nurse stated that she typically scheduled the MDS assessment for seven days after admission and aimed to complete it one week after the assessment reference date (ARD). She acknowledged that the assessment was not completed on time because she was on vacation, and it should have been finished two days prior. The Director of Nursing confirmed the expectation that the admission MDS be completed by the 14th day of admission.
Failure to Complete Required PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments were properly reviewed, completed, and submitted for two residents with mental health diagnoses. For one resident admitted with anxiety and depression and identified as moderately cognitively impaired, the PASRR indicated a Mood Disorder and noted an exempted hospital discharge, stating that a Level II evaluation was required if the resident remained beyond 30 days. However, no further PASRR was completed or transmitted after the resident stayed past the 30-day period. The Social Service Director acknowledged during interview that the review was missed and should have been completed. Similarly, another resident admitted with major depressive disorder was documented as alert and oriented, and their PASRR Level 1 assessment also indicated an Exempted Hospital Discharge with the requirement for a Level II evaluation if the stay exceeded 30 days. Record review showed no evidence that a new PASRR Level 1 or Level II was completed after the resident remained in the facility beyond the anticipated discharge period. The Social Service Director confirmed responsibility for PASRR referrals and admitted not submitting the required referral for a Level II evaluation, having not realized the resident's stay had exceeded 30 days.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect care needs following multiple falls. A resident with a history of repeated falls was admitted with multiple diagnoses and was assessed as cognitively intact. The facility's records showed that the resident experienced falls on two separate occasions in August, and documentation from fall investigations indicated that the care plan was updated to cue and encourage the resident to use the call light and wait for help. However, review of the resident's fall care plan revealed that after the second fall, no new revision or intervention was documented to address the most recent incident. Interviews with facility staff confirmed that the expected process after a fall was to update the care plan with a new intervention. The Resident Care Manager/LPN acknowledged that a new intervention should have been added after the second fall but stated it was missed. The Director of Nursing/RN also confirmed the expectation that the care plan be updated after each fall. This deficiency was identified through interview and record review, as the care plan did not reflect the resident's most current care needs following the second fall.
Failure to Follow Physician Orders for Weights and PICC Line Care
Penalty
Summary
The facility failed to follow physician's orders for daily weights for a resident with multiple diagnoses, including congestive heart failure. The resident was admitted with severe cognitive impairment, and the physician's orders specified daily weights for one week, then weekly weights unless otherwise ordered. Review of the electronic health record showed missing documentation of weights on several specified dates, indicating that the ordered monitoring was not completed as required. During an interview, the Resident Care Manager/Registered Nurse acknowledged that some weights were missed. Additionally, the facility did not adhere to physician's orders regarding medication administration for another resident with endocarditis and a peripherally inserted central catheter (PICC) line. The orders required flushing the PICC line and checking for blood return before each medication administration. During an observed medication pass, a registered nurse flushed the PICC line and started IV antibiotics without checking for blood return as ordered. When questioned, the nurse stated that blood return had been checked the previous day during a blood draw, but not at the time of the medication administration.
Failure to Complete Shift Pain Assessments for Cognitively Impaired Resident
Penalty
Summary
The facility failed to complete pain assessments every shift for a resident with multiple chronic pain-related diagnoses, including vascular dementia, fibromyalgia, and chronic pain syndrome. The resident was severely cognitively impaired and unable to consistently verbalize pain, requiring staff to use both verbal and non-verbal pain assessment tools. Documentation showed that the care plan and hospice plan of care required regular pain monitoring and assessment using appropriate scales. However, record review revealed that pain assessments were not consistently completed every shift as required. Observations and interviews indicated that the resident experienced ongoing pain, including pain related to a right heel deep tissue injury and generalized discomfort. Staff interviews confirmed that pain assessments were supposed to occur every shift, but this was not consistently documented or ordered. The lack of regular pain assessments placed the resident at risk for unmet care needs and diminished quality of life, as noted in the report.
Sharps Containers Overfilled Due to Lack of Monitoring Process
Penalty
Summary
Sharps containers in two resident rooms were observed to be filled above the designated fill line, as indicated by the warning label on the containers. During observations, the overfilled containers caused the lids to malfunction, with sharps instruments catching on the lid and protruding toward the opening, creating a potential hazard. The containers were not dated consistently, and the issue was noted during multiple observations by surveyors. Staff interviews revealed that there was no clear assignment of responsibility for monitoring or emptying sharps containers, with both nursing and environmental services staff stating they would empty the containers if they noticed they were full. However, there was no established process or department designated to regularly check and replace the containers when full. Staff members, including a registered nurse and the Environmental Services Supervisor, acknowledged that the containers should be emptied at the fill line but confirmed that no specific protocol or department was responsible for this task. The Director of Nursing also stated the expectation that staff would change the containers when they reached the full line. The lack of a defined process led to the containers being overfilled, as observed by surveyors, and placed residents, visitors, and staff at risk for injury and exposure.
Failure to Provide Required Survey Results in Public Binder
Penalty
Summary
The facility failed to ensure that its survey result binder included the required health recertification and complaint survey results for two of the three years reviewed, specifically for 2024 and 2025. During an observation, the survey binder was found in a wall-mounted receptacle near the skilled nursing entrance and was labeled as containing the three most current years of survey reports. However, upon review, the binder only contained a Federal Fire and Life Safety recertification survey and its re-inspection from 2024, with no health recertification or health complaint investigation survey results for 2024 or 2025. Interviews with the DON and the Administrator revealed that only one survey binder was maintained, and the Administrator admitted to not including complaint investigation surveys in the binder, typically only placing annual survey results. The Administrator also stated that the survey results were not available last year and could not be found online.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for four of nine sampled residents. This deficiency was identified through interviews and record reviews. The facility's policy on advance directives, dated August 1, 2018, requires determining whether a resident has an AD upon admission and providing information about the right to refuse treatment and formulate an AD. However, the electronic health records (EHR) for Residents 1, 24, 26, and 30 did not show any AD or documentation that an AD was reviewed since their admission. Resident 1 was severely cognitively impaired, Resident 24 was moderately cognitively impaired, and Residents 26 and 30 were alert and oriented. Despite these varying cognitive statuses, none of their EHRs contained the necessary AD documentation. Staff K, the Social Services Director, acknowledged gaps in documentation and follow-up, while Staff A, the Administrator, confirmed that ADs should be reviewed and addressed at the initial care conference. The lack of proper documentation and follow-up placed residents at risk of not having their healthcare preferences and decisions honored.
Failure to Obtain Physician Orders for Bed Rails
Penalty
Summary
The facility failed to obtain a physician's order for the use of physical restraints for two residents, which is a requirement according to their policy. Resident 3, who was moderately cognitively impaired, was observed multiple times with quarter length bed rails on both sides of their bed. Despite these observations, a review of Resident 3's Electronic Health Record (EHR) revealed no physician's order for the bed rails. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged that a physician's order was necessary for such enablers, but none was found for Resident 3. Similarly, Resident 288, who was alert and oriented, was observed with quarter length bed rails on both sides of her bed on several occasions. A review of her EHR also showed no physician's order for the use of these bed rails. The absence of physician orders for these enablers was confirmed by staff, indicating a failure to adhere to the facility's policy and procedure regarding the use of devices/enablers.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for a resident reviewed for transfer notice requirements. This deficiency was identified during an interview and record review. The resident, who was admitted to the facility with diagnoses including congestive heart failure exacerbation and physical deconditioning, was transferred to a local hospital. The facility administrator, Staff A, acknowledged that he was unaware of the requirement to send a copy of the Notice of Transfer to the Ombudsman and only sent out the notices for the months of June, July, and August after being questioned about it.
Inaccurate MDS Assessment of Resident's Oral/Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's oral/dental status, specifically for a resident identified as severely cognitively impaired. The MDS assessment documented that the resident did not have tooth fragments or broken natural teeth, had no mouth pain, and was able to be examined. However, a Nutrition Assessment and a Nutrition/Dietary progress note both documented that the resident's natural teeth were in poor shape. Observations on multiple occasions revealed that the resident had missing upper teeth, lower teeth with sharp edges, and dark tan coloration, and the resident reported experiencing mouth pain. Staff interviews revealed that the MDS Nurse, responsible for gathering information for the MDS, did not personally assess the resident's oral/dental status and relied on medical records and staff input. The Director of Nursing Services acknowledged the inaccuracy of the MDS oral/dental status and indicated the need for a correction. The failure to conduct a visual assessment of the resident's oral/dental status led to the inaccurate documentation in the MDS, placing the resident at risk for unidentified and unmet care needs.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was severely cognitively impaired. The resident's care plan did not address the placement of the bed against the wall and the use of a mat on the floor, which were observed multiple times during the survey. The facility's policy required that such devices or enablers be appropriately care planned and added to the resident's Kardex, but this was not done for the resident in question. Staff members, including a Certified Nursing Assistant and the Resident Care Manager, acknowledged that the care plan should have included the bed and mat arrangements. The Director of Nursing Services also confirmed that it was expected for care plans to be in place for residents with their bed against the wall and mats on the floor. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for assistance with activities of daily living (ADLs). The facility's policy stated that nail care is part of personal hygiene and should be provided by a certified nursing assistant unless the resident is diabetic, in which case a licensed nurse should perform the task. Resident 5, who was severely cognitively impaired and required substantial assistance with personal hygiene, had not received nail care for about a month, despite expressing a desire for assistance. The resident's last documented bath or shower was on August 31, 2024, and by September 10, 2024, their fingernails were approximately 1/3 inch long. Staff interviews revealed that nail care was supposed to be performed during baths or showers, but this was not done for Resident 5. The Nursing Assistant confirmed that they checked nails during baths, and the Director of Nursing Services stated that nail care should be done by the shower aid unless the resident was diabetic. Upon observation, the Director of Nursing Services noted that Resident 5's nails appeared to have not been trimmed for about two weeks, indicating a lapse in the facility's adherence to its own nail care policy.
Failure to Explain Arbitration Agreement Properly
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to a resident, identified as Resident 25, who was part of a sample reviewed for arbitration agreements. The resident was admitted and readmitted to the facility, with assessments indicating she was alert and oriented. However, nursing notes documented instances of confusion and forgetfulness. Despite this, the arbitration agreement was signed by the resident and the Admissions Coordinator, Staff J, on a specified date. During an interview, Resident 25 could not recall signing the agreement or having it explained to her, citing pain from a broken hip and uncertainty about the document's meaning. Staff J, responsible for determining a resident's capability to sign such agreements, admitted to not informing residents or their representatives about the 30-day period to rescind the agreement. Staff J believed residents could change their minds at any time, a misunderstanding shared by the facility's Administrator, Staff A, who also did not know the correct rescission period. This lack of awareness and communication placed residents at risk of signing legal documents without full understanding or knowledge of their rights.
Infection Control Deficiency in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention practices, specifically in the use of personal protective equipment (PPE) and hand hygiene, for two residents. In one instance, a Certified Nurse Assistant (CNA) was observed providing care to a resident, removing her gloves, and then retrieving new gloves from an isolation cart without performing hand hygiene in between. This CNA acknowledged that she should have washed her hands between changing gloves. In another instance, two CNAs entered a resident's room, which had an enhanced barrier precautions sign, without wearing isolation gowns. One of the CNAs was observed taking trash out of the room and entering a code on a door with contaminated gloves, then returning to the resident's room and sanitizing her hands only after removing the gloves. The CNA was unsure of the resident's isolation status and admitted to using contaminated gloves outside the resident's room. The Director of Nursing Services confirmed that infection control training was provided and that staff were expected to follow isolation precaution signs and perform hand hygiene before leaving a resident's room.
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Illustrative
What surveyors actually found near you
We read the 127 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Centralia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Three Rivers Care | 1.4 mi | — | 14 | 0 |
| South Creek Post Acute | 1.5 mi | — | 21 | 0 |
| Lacey Post Acute & Rehabilitation | 19.9 mi | — | 8 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 21.1 mi | — | 15 | 0 |
| Puget Sound Care | 21.4 mi | — | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.