Inspection Reports for Sharon Care Center
1509 Harrison Ave, Centralia, WA 98531, United States, WA, 98531
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
159% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
62 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 1
Dec 1, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to toileting assistance for residents, specifically reviewing care for two sampled residents regarding Activities of Daily Living (ADL) care.
Findings
The facility failed to provide adequate toileting assistance to 2 of 5 sampled residents, resulting in risks of skin infections, diminished dignity, and reduced quality of life. Staff did not consistently check and change residents' briefs every two hours as required, leading to residents being found with soiled briefs and bedding.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide toileting assistance according to care plans, resulting in residents being found with dried bowel movements and saturated briefs due to lack of timely checks and changes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents reviewed: 5
Residents affected: 2
Date of survey completed: Dec 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Reported finding dried bowel movement on Resident 1 and failure to check/change briefs as scheduled |
| Staff B | Director of Nursing/Registered Nurse | Provided expectations for toileting assistance and confirmed findings during facility investigation |
| Staff E | Residential Care Manager/Registered Nurse | Conducted investigation regarding Resident 2's toileting assistance issues |
| Staff F | Certified Nursing Assistant | Observed Resident 2 with soaked incontinence pad and reported failure to change during night |
Inspection Report
Annual Inspection
Deficiencies: 9
Sep 12, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements including survey result availability, medication administration, resident assessments, care planning, pain management, food safety, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to maintain survey result binders with all required surveys, incomplete medication side effect assessments, delayed resident admission assessments, incomplete PASRR screenings, failure to update care plans after falls, missed daily weights and PICC line checks, incomplete pain assessments, improper food labeling and temperature logging, and unsafe sharps container management.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure the survey result binder included health recertification and complaint survey results for 2 of 3 years reviewed. | Level of Harm - Potential for minimal harm |
| Failed to complete an AIMS test for 1 of 5 residents receiving antipsychotic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete resident admission Minimum Data Set (MDS) within required timeframe for 1 of 10 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure PASRR assessment was reviewed, completed, and submitted for 2 of 5 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise resident care plans to accurately reflect care needs after falls for 1 of 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain daily weights per physician's orders for 1 of 5 residents and failed to check PICC line blood return for 1 of 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete pain assessments every shift for 1 of 5 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food items were labeled and dated when opened and failed to keep accurate temperature logs for nourishment refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain safe, sanitary, and comfortable environment by allowing sharps containers to be overfilled in 2 of 7 rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication side effects: 5
Residents reviewed for admission assessments: 10
Residents reviewed for PASRR: 5
Residents reviewed for care plan accuracy: 3
Residents reviewed for quality of care: 5
Residents reviewed for pain management: 5
Rooms reviewed for environment: 7
Expired food items observed: 5
Missed temperature log dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing/Registered Nurse | Named in multiple findings including survey binder, AIMS test expectations, MDS completion, care plan updates, food labeling, and sharps container management |
| Staff A | Administrator | Named in survey binder deficiency regarding posting survey results |
| Staff C | Resident Care Manager/Registered Nurse | Named in AIMS test, weights, pain assessment, and medication administration deficiencies |
| Staff E | MDS Nurse/Registered Nurse | Named in MDS completion deficiency |
| Staff G | Resident Care Manager/Licensed Practical Nurse | Named in care plan revision deficiency |
| Staff F | Registered Nurse | Named in PICC line medication administration deficiency |
| Staff H | Social Service Director | Named in PASRR screening deficiency |
| Staff L | Dietary Manager | Named in food labeling and temperature log deficiency |
| Staff J | Registered Nurse | Named in sharps container management deficiency |
| Staff K | Environmental Services Supervisor | Named in sharps container management deficiency |
| Staff D | Nursing Assistant | Named in pain assessment deficiency |
Inspection Report
Life Safety
Deficiencies: 8
Jul 10, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Sharon Care Center Assisted Living to evaluate compliance with fire safety and protection codes.
Findings
The facility was disapproved due to multiple failures including lack of annual inspection of fire resistance rated construction, failure to provide annual fire door inspection report, fire doors obstructed with items, failure to provide 4-year fire damper inspection report, failure to provide 5-year FDC hydrostatic and internal inspection reports, failure to provide monthly carbon monoxide detector testing for June 2025, failure to provide emergency lighting testing for June 2025, and failure of generator fuel testing.
Deficiencies (8)
| Description |
|---|
| Facility failed to provide annual inspection of fire resistance rated construction |
| Facility failed to provide annual fire door inspection report; fire doors found to have items on doors such as wreaths |
| Facility failed to provide 4 year fire damper inspection report |
| Facility failed to provide 5 year FDC hydrostatic inspection |
| Facility failed to provide 5 year internal inspection report |
| Facility failed to provide monthly carbon monoxide detector testing for June 2025 |
| Facility failed to provide emergency lighting testing for June 2025 |
| Generator fuel testing failed |
Report Facts
Inspection date: Jul 10, 2025
Next inspection scheduled: Aug 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Blood | Administrator | Named as Owner's Representative and Administrator signing the inspection report |
| Nicholas Wolden | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 4, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication services.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to medication availability were corrected.
Report Facts
Total residents: 67
Resident sample size: 3
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Horlick | NCI RN Complaint Investigator | Investigator who conducted complaint investigation |
| Anissa Bearden | Licensor | Department staff who did the on-site verification during follow-up inspection |
| Staff D | Medication Technician | Named in medication availability deficiency related to Resident 1 |
| Staff B | Director of Nursing | Interviewed regarding medication availability and processes |
| Staff A | Executive Director | Interviewed regarding medication reordering policies |
| Staff C | Resident Care Coordinator | Interviewed regarding medication refill fax errors |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Mar 11, 2025
Visit Reason
The investigation was conducted due to complaints regarding quality of care/treatment related to a resident fall with injury in the community and a possible flu outbreak in the facility.
Findings
The facility investigated the resident fall incident appropriately with no failed practice. However, the facility failed to notify the Local Health Jurisdiction and Complaint Resolution Unit about the confirmed flu outbreak, which was identified as a failed practice.
Complaint Details
Complaint investigation involved allegations of quality of care/treatment due to a resident fall with injury and infection control due to a possible flu outbreak. The infection control allegation was substantiated with failed practice identified; the quality of care allegation was not substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to report communicable diseases in accordance with infection control requirements during an influenza outbreak, placing all residents at risk. |
Report Facts
Total residents: 62
Resident sample size: 4
Date of resident fall report: Feb 9, 2025
Date of second resident fall report: Feb 6, 2025
Number of positive residents during flu outbreak: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aube | ALF NCI Investigator | Investigator who conducted the complaint investigation and on-site verification |
| Cory Cisneros | Field Manager | Signed correspondence related to the inspection and compliance |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Nov 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a report that a resident was not receiving pain medication when needed.
Findings
The facility did not have a facility reported incident report available for review while on site but was able to produce and provide an incident report by the end of the visit. Consultation was provided. No failed provider practice or citation was identified.
Complaint Details
Complaint investigation related to quality of care/treatment alleging a resident did not receive pain medication when needed. The complaint was not substantiated as no failed provider practice or citation was written.
Report Facts
Total residents: 66
Resident sample size: 7
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Horlick | NCI RN Complaint Investigator | Investigator who conducted the complaint investigation |
| Cory Cisneros | Field Manager | Field Manager who signed the letter |
Inspection Report
Annual Inspection
Deficiencies: 8
Sep 13, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident rights, use of restraints, transfer notifications, assessment accuracy, care planning, activities of daily living, arbitration agreements, and infection control.
Findings
The facility was found deficient in several areas including failure to assist residents with advance directives, lack of physician orders for physical restraints, failure to send timely transfer notices to the Ombudsman, inaccurate Minimum Data Set assessments, incomplete care plans, inadequate assistance with activities of daily living such as nail care, failure to properly explain arbitration agreements, and lapses in infection prevention practices including improper use of PPE and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide and/or have procedures in place to assist with completing advance directives and maintaining Durable Power of Attorney documentation for 4 of 9 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a physician's order for physical restraints for 2 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a copy of the Notice Before Transfer was sent to the Office of the State Long-Term Care Ombudsman for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the Minimum Data Set assessment accurately reflected a resident's oral/dental status for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive care plan addressing specific resident needs for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities of daily living care including nail care for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to explain the arbitration agreement in a manner understood by the resident or representative for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection prevention practices including proper use of PPE and hand hygiene for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Social Services Director | Named in advance directives documentation and follow-up deficiency |
| Staff A | Administrator | Named in advance directives and transfer notice deficiencies |
| Staff C | Resident Care Manager and Registered Nurse | Named in physical restraints and care plan deficiencies |
| Staff B | Director of Nursing Services and Registered Nurse | Named in physical restraints, MDS assessment, care plan, ADL care, and infection prevention deficiencies |
| Staff D | Certified Nursing Assistant | Named in care plan deficiency |
| Staff E | MDS Nurse and Registered Nurse | Named in MDS assessment accuracy deficiency |
| Staff I | Nursing Assistant | Named in ADL care deficiency |
| Staff J | Admissions Coordinator | Named in arbitration agreement deficiency |
| Staff F | Certified Nurse Assistant | Named in infection prevention deficiency |
| Staff G | Certified Nurse Assistant | Named in infection prevention deficiency |
| Staff H | Certified Nurse Assistant | Named in infection prevention deficiency |
Inspection Report
Life Safety
Deficiencies: 1
Sep 4, 2024
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Sharon Care Center Assisted Living on 09/04/2024.
Findings
The inspection found that all violations noted during previous related inspections had been corrected. The prior inspection on 06/26/2024 identified fire doors with excessive gaps, which was cited as a violation.
Deficiencies (1)
| Description |
|---|
| Fire doors found throughout to have excessive gap. |
Report Facts
Inspection date: Sep 4, 2024
Previous inspection date: Jun 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| J R Blood | Administrator | Owner's representative who signed the report |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 5, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 07/05/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements.
Report Facts
Sample size: 12
Deficiency count: 5
Staff sample size: 5
Staff sample size: 3
Residents with missing negotiated service agreements: 3
Residents with missing signed negotiated service agreements: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Medication Assistant | Failed to complete national fingerprint background check; hired 08/17/2023 |
| Staff D | Medication Assistant | Failed to complete required training; hired 01/25/2023 |
| Staff B | Director of Nursing Services | Acknowledged missing fingerprint check for Staff E and incomplete training for Staff D and E; acknowledged missing negotiated service agreements |
| Kyle Gehlen | ALF Licensor - LTC | Department staff who inspected the facility |
| Jennifer Siharath | ALF Licensor | Department staff who inspected the facility |
| Yvonne Chitekwe | Department staff who inspected the facility | |
| Anissa Bearden | Licensor | Department staff who did on-site verification for follow-up inspection |
| Celeste Vashey | ALF LTC Licensor | Department staff who did on-site verification for follow-up inspection |
Inspection Report
Routine
Deficiencies: 19
Jul 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain consents for psychotropic medications, incomplete care plans, inadequate monitoring of medication side effects, unsafe storage of tools and chemicals, improper catheter care, failure to timely submit resident assessments, and unsanitary kitchen conditions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 19
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to obtain documentation of consents for psychotropic medications for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents were evaluated, assessed and had physician orders for safe self-administration of medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure mail delivery was provided on Saturdays for residents receiving mail via the US Postal Service. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain, provide, and/or assist with completing Advance Directives for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to issue Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage and/or Notice of Medicare Non-Coverage timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a system was in place to resolve grievances promptly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician orders and consents were obtained for physical restraints. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written bed-hold notice to resident or representative at time of hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to encode and transmit resident assessment data to the State within required timeframe. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop comprehensive care plans addressing all resident needs including UTI, dementia, edema, and bed placement. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to review, revise, and accurately reflect resident care needs in care plans after condition changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to initiate bowel protocol per physician orders and when needed for constipation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe environment free from accident hazards related to unsecured tools and chemicals. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents with indwelling urinary catheters had valid medical diagnosis and complete provider orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor anticoagulant medication related complications for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor psychotropic medication side effects and limit PRN psychotropic medications to 14 days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prepare, store, and serve food in a sanitary manner including kitchen cleanliness and proper storage of utensils and opened foods. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper hand hygiene and glove changes by kitchen staff during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper catheter care including preventing catheter bags from lying on the floor. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 42
Staff affected: 1
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing Services and RN | Named in multiple findings including expectations for medication monitoring, catheter care, and safety |
| Staff D | Resident Care Manager and Registered Nurse | Named in findings related to medication consent, care planning, and monitoring |
| Staff E | Infection Preventionist and Registered Nurse | Named in findings related to infection prevention, catheter care, and hand hygiene |
| Staff F | Social Services | Named in findings related to Advance Directives and grievance resolution |
| Staff G | Licensed Practical Nurse and MDS Coordinator | Named in findings related to resident assessment submission and care plan updates |
| Staff J | Registered Nurse | Named in findings related to catheter care and care plan revisions |
| Staff K | Resident Care Manager and Licensed Practical Nurse | Named in findings related to care planning and chemical storage |
| Staff N | Dietary Manager | Named in findings related to kitchen sanitation and food safety |
| Staff O | Dietary Cook | Named in findings related to hand hygiene during meal service |
| Staff P | Registered Nurse | Named in findings related to infection prevention and catheter care |
| Staff Q | Maintenance Director | Named in findings related to unsecured tools during room construction |
| Staff I | Social Services Director | Named in findings related to SNF ABN/NOMNC notification and psychotropic medication monitoring |
| Staff L | Certified Nursing Assistant | Named in findings related to catheter bag placement |
| Staff M | Certified Nursing Assistant | Named in findings related to catheter care |
| Staff C | Licensed Practical Nurse | Named in findings related to psychotropic medication consent and monitoring |
Inspection Report
Life Safety
Deficiencies: 2
Jun 7, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Sharon Care Center Assisted Living to assess compliance with fire safety and code requirements.
Findings
The inspection found a violation related to the commercial cooking system: the cooking appliance under the hood was not aligned with the nozzle configuration, and required signage was missing or inadequate. Previous violations noted in earlier inspections have been corrected.
Deficiencies (2)
| Description |
|---|
| Cooking appliance under hood shall be in alignment with nozzle configuration |
| Signage shall indicate appliances from left to right, be durable and the size, color, and lettering shall be approved |
Report Facts
Next inspection scheduled date: Jul 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Wolden | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Terry Myers | Campus Administrator | Owner or Authorized Representative signing the report |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 10, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Salas | ALF Complaint Investigator | Department staff who did the on-site verification |
| Celeste Vashey | ALF LTC Licensor | Department staff who did the on-site verification |
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