Inspection Reports for
Sharon Care Center

The facility failed to ensure that Resident 1, who was at risk for dehydration and malnutrition, received the ordered restorative nursing aide feeding program at both breakfast and lunch, resulting in unplanned severe weight loss of 9.4% over three months. This failure placed the resident at risk for further decline and complications related to protein-calorie malnutrition.

The complaint investigation focused on Resident 1, who was refusing to eat and had a deteriorating sacral pressure ulcer. The facility failed to notify the physician and family about the change in condition, failed to implement physician orders, and failed to conduct proper care planning. Resident 1 was transferred to hospital with severe complications and expired on 11/15/2025.

The facility failed to notify the physician and family about Resident 1's declining condition, failed to carry out physician orders including IV fluids and lab tests, failed to conduct interdisciplinary team meetings including the resident or representative, and failed to prevent deterioration of pressure ulcers. These deficiencies contributed to Resident 1's severe dehydration, infection, and eventual death.

The facility failed to revise care plans for residents after significant changes in their conditions, including failure to update care plans after urinary catheter removal and reinsertion, failure to update care plans after hospital readmission for respiratory failure, and failure to properly dispose of and label feeding tube supplies. These deficiencies placed residents at risk for urinary retention, infection, sepsis, aspiration, and inadequate management of respiratory status.

The complaint was substantiated based on observations, interviews, and record reviews showing deficient pain management practices for Resident 2.

The facility failed to manage pain effectively for Resident 2 by not notifying the physician when the resident continued to experience pain after medication and requested more frequent dosing. This resulted in the resident remaining uncomfortable and waiting longer than appropriate for pain relief.

The facility failed to assist and make transportation arrangements for recurring chemotherapy appointments for one sampled resident, which had the potential to result in the resident missing treatment. The facility acknowledged that transportation was not booked until the day of the appointment, contrary to policy.

The facility was found deficient in multiple areas including medication administration without proper orders, failure to provide warm water for resident preferences, inadequate care planning for hearing impairment, improper pressure ulcer prevention measures, unsafe environmental hazards, failure to notify physicians of catheter sediment, unlabeled feeding tube syringes, lack of emergency dialysis kits, improper medication storage, food safety violations, infection control lapses, inadequate room space for residents, and malfunctioning call light systems.

The facility failed to ensure that one sampled resident's (Resident 3) PRN psychotropic medication order had a documented 14-day stop date, resulting in an increased risk to the resident's mental and psychosocial well-being. Interviews and record reviews confirmed that the PRN Seroquel orders lacked the required 14-day limit and were not discontinued as per facility policy.

The complaint investigation focused on Resident 1, who had diagnoses including schizophrenia and mood disorder. The facility failed to complete PASARR Level II screening, notify the physician after significant behavioral changes, and update the care plan accordingly. Resident 1 exhibited verbal aggression and agitation, resulting in a 5150 psychiatric hold and transfer to General Acute Care Hospital (GACH). The Director of Nursing and other staff acknowledged these failures during interviews.

The facility failed to ensure accurate PASARR screening and follow-up for Resident 1, did not notify a physician after a significant change in Resident 1's mental and physical condition, and failed to update and implement a comprehensive care plan addressing Resident 1's behavioral symptoms and medication interventions. These deficiencies contributed to Resident 1's behavioral escalation and hospitalization.

The complaint investigation found substantiated deficiencies related to care planning, pressure ulcer prevention, and staffing adequacy affecting multiple residents.

The facility failed to develop and implement baseline care plans for pain management and fracture care for Resident 1, did not ensure proper assessment and monitoring of Resident 1's left lower leg splint, and failed to provide sufficient nursing staff to assist residents with basic care and scheduled showers, affecting Residents 1, 4, and 5.

The complaint investigation found that the facility did not promptly notify the physician or transfer Resident 1 emergently despite critically low platelet counts, resulting in delayed hospital transfer and increased risk of bleeding. Resident 1 died seven days later at the hospital.

The facility failed to ensure timely recognition and communication of critically low platelet counts for Resident 1, resulting in delayed transfer to a hospital and increased risk of spontaneous bleeding. Interviews with nursing staff and the Director of Nursing revealed lapses in following emergency protocols and notification procedures. The resident subsequently died seven days after transfer.

The facility failed to honor food preferences for two residents by providing only canned fruits instead of fresh fruits. Additionally, the facility did not ensure that dinnerware and food service equipment were clean and in good condition, including stained cups, worn coffee pot lids, and improperly changed water pitchers.

The facility failed to develop a comprehensive care plan for a resident with bipolar disorder and psychotropic medication, lacked yearly performance evaluations for a licensed vocational nurse, did not maintain a yearly skills competency checklist for a certified nurse assistant, and failed to obtain documented consent for psychotropic medications for the resident. These deficiencies posed minimal harm or potential for actual harm to a few residents.

The complaint investigation focused on an incident between Resident 1 and Resident 7 involving resident-to-resident abuse. The facility failed to report the incident to the state licensing/certification office, police, and ombudsman, did not investigate the incident, and did not separate the residents promptly. Both residents initially refused room changes. The facility administrator did not report the incident, considering it only an argument without injury.

The facility failed to timely report a resident-to-resident abuse incident to the state licensing office, police, and ombudsman, did not investigate the incident, and did not separate the residents in a timely manner. The incident involved two residents arguing and attempting to strike each other, with delayed room changes and no official reporting or investigation.

The complaint investigation found that Resident 2 was mistakenly transported to a skilled nursing facility instead of an ophthalmologist appointment due to confusion over residents with the same first name. Resident 2 missed the appointment and was upset. Additionally, Resident 1 had a fall during the night shift that was not documented immediately, and the physician was not notified promptly.

The facility failed to ensure correct resident identification during transportation, resulting in Resident 2 being taken to the wrong location and missing an ophthalmologist appointment. Additionally, the facility failed to assess Resident 1 immediately after a fall and did not notify the physician or responsible party promptly.

The facility failed to ensure that one sampled resident with pressure ulcers had quarterly Braden scale assessments completed and that care plans were properly developed and revised to reflect changes in wound status. This included failure to develop a care plan for a new vascular wound and failure to revise the care plan when a pressure ulcer was reclassified to Stage IV. These deficiencies posed an increased risk of worsening skin integrity and delayed healing.

The complaint investigation was substantiated based on interviews, observations, and record reviews confirming verbal abuse by CNA 1 toward Resident 1 on 8/12/2024. The Director of Nursing and Administrator acknowledged the inappropriate communication and reviewed facility policies on abuse prohibition.

The facility failed to protect Resident 1 from verbal abuse when CNA 1 used a derogatory word during an interaction about the resident's socks. Multiple interviews and observations confirmed the use of inappropriate language by CNA 1, which caused Resident 1 mental anguish. The facility's policies prohibit such verbal abuse and require effective communication.

The facility failed to ensure proper billing for a single room when another resident was on bed hold, delayed following dietitian recommendations for gastrostomy feeding formula changes resulting in weight loss, and did not develop or timely revise care plans and interdisciplinary team meetings for feeding tube dislodgements, leading to multiple replacements.

The facility was found deficient in multiple areas including failure to provide required notices to residents regarding Medicare coverage, inadequate follow-up on missing resident property, failure to notify the Ombudsman of resident transfers, lack of care plans for medications, delays in physician consultations, failure to follow medication orders, inadequate fall prevention measures, failure to monitor and address severe weight loss, incomplete staff competency evaluations, lack of informed consent for psychotropic medications, failure to rotate insulin injection sites, expired medication storage, unsanitary food storage conditions, incomplete hospice documentation, insufficient resident room space, and call light accessibility issues.

The visit was complaint-related, focusing on substantiation of failure to provide ordered compression therapy for Resident 1. The deficiency was substantiated with observations and record review confirming non-compliance with physician orders.

The facility failed to ensure that Resident 1 received ordered bilateral compression sleeves and stockings for lymphedema management, resulting in potential harm including swelling, pain, decreased blood flow, and tissue death. Observations showed inconsistent use of compression devices despite physician orders, and the Director of Nursing confirmed the orders and the requirement to notify the doctor if the resident could not tolerate the devices.

The facility failed to remove discontinued gabapentin 300 mg medication from the medication cart for one resident, which posed a potential medication error risk. Interviews and record reviews confirmed the presence of the discontinued medication and the need for its removal according to facility policy.

The complaint investigation found that the facility did not report the physical altercation between Resident 1 and Resident 2 within the required two hours to the local California Department of Public Health. The report was faxed the following morning, resulting in a delay of the investigation. The complaint was substantiated based on interviews and record reviews.

The facility failed to report the physical altercation involving two residents to the local California Department of Public Health within the required two-hour timeframe, resulting in a delayed onsite inspection and potential increased risk to the residents.

The facility failed to ensure staff wore masks during a COVID-19 outbreak, failed to offer influenza vaccination to two of six sampled residents, and failed to offer or document COVID-19 vaccination for six sampled residents, resulting in COVID-19 infections among those residents.

The complaint was substantiated based on interviews and record reviews indicating the facility's failure to timely administer medication and treat Resident 1 respectfully, including LVN 1's loud voice and delayed medication administration.

The facility failed to assess and administer acetaminophen to Resident 1 in a timely manner on 11/7/2023, and a Licensed Vocational Nurse (LVN 1) went on a meal/rest break before giving the medication. Additionally, LVN 1 did not lower her voice when requested by Resident 1, resulting in the resident feeling disrespected and upset.

The visit was complaint-related, focusing on allegations of failure to provide psychosocial follow-up after abuse, failure to arrange home health services upon discharge, and failure to conduct required interdisciplinary team meetings. The deficiencies were substantiated with evidence from interviews and record reviews.

The facility failed to provide psychosocial follow-up for Resident 1 after an alleged abuse incident, failed to arrange home health services for Resident 3 upon discharge, and failed to conduct an interdisciplinary team meeting for Resident 3 within 72 hours of admission. These deficiencies had the potential to negatively impact resident care and safety.

The complaint investigation was substantiated. Resident 1 reported being restrained and catheterized without consent on 7/6/2023, resulting in trauma, pain, and emotional distress. The facility suspended involved staff, conducted investigations, and implemented corrective actions including education and psychological support for Resident 1.

The facility failed to protect Resident 1 from physical and mental abuse by three employees who restrained her and performed straight catheterization without her consent, causing pain and emotional distress. Additionally, the facility failed to obtain physician orders for straight catheter urine collection for Residents 1, 2, and 3, violating professional standards of care.

The visit was complaint-related, focusing on whether the resident's representative was included in care planning. The complaint was substantiated as the representative was not included in IDT meetings from 1/2023 to 7/2023.

The facility failed to include the resident's representative in the IDT meetings for one of three sampled residents, which potentially compromised meeting the resident's needs. Interviews and record reviews confirmed that the resident's representative was not involved in care planning from January to July 2023, contrary to the facility's policy encouraging family participation.

The complaint investigation found substantiated failures in diabetes management and emergency response, including lack of blood sugar reassessment after insulin administration and delayed CPR initiation leading to resident death.

The facility failed to reassess a resident's blood sugar after administering insulin, potentially leading to ineffective diabetes management. Additionally, the facility staff delayed initiating CPR when the resident was found unresponsive on the floor, contrary to facility policies, which contributed to the resident's death.

The facility failed to conduct required interdisciplinary team meetings for Resident 1 since admission and failed to ensure monthly physician face-to-face visits from January 2023 to June 5, 2023. These deficiencies had the potential to delay necessary care and result in missed or delayed treatment.

The facility failed to provide a copy of medical records upon written request for one of three sampled residents, violating the resident's legal right to access their records. The deficiency was related to delays in providing access to protected health information as required by federal and state regulations.

The complaint was substantiated based on Resident 1's report and confirmation by Resident 2, the roommate and witness. CNA 1 denied the allegation but resigned before the investigation was completed.

The facility substantiated the allegation that CNA 1 called Resident 1 'stupid' during a night shift, which constituted verbal abuse. Resident 1 was cognitively impaired but alert and oriented, and the incident was witnessed by Resident 2. CNA 1 resigned before the investigation was completed.

The facility failed to develop a specific care plan for Resident 1's repeated G-Tube dislodgements and did not notify the physician that Resident 1 had not received IV fluids for 12 hours as ordered. These deficiencies resulted in multiple hospital visits and potential harm due to dehydration and low blood sugar.

The complaint involved allegations that CNA 1 refused to give Resident 1 snacks brought by family and made comments about Resident 1 being 'too fat.' The allegation was reported by Resident 1 to CNA 2, who informed LVN 1. The facility failed to notify the abuse coordinator and did not report the allegation to the Department of Public Health in a timely manner.

The facility failed to protect Resident 1 from mental and verbal abuse by CNA 1, resulting in the resident feeling uncomfortable. Additionally, the facility failed to timely report the alleged abuse to the Department of Public Health, resulting in Resident 1 not receiving a proper investigation.

The facility failed to maintain a belongings inventory list for one sampled resident, resulting in potential psychological harm. Additionally, the facility failed to provide the RNA program for Resident 1 for multiple days across several months in 2020, increasing the risk of mobility and range of motion decline.

The facility was found deficient in multiple areas including resident dignity and privacy, medication self-administration, call light accessibility and response, infection control practices, staff competency and identification, medication administration documentation, resident care planning, supervision to prevent accidents, food safety and preparation, staffing levels, and COVID-19 vaccination and screening protocols.