Sharon Care Center: Care Plan Failures for Mental Health - CA
The incident occurred on January 14, 2025, when the resident became "increasingly agitated" because she wanted her medication schedule changed from 9 p.m. to 7:30 p.m. According to a clinical assessment form, the resident told staff: "I will pull your hair if you don't give me the medication."
Staff documented the threat as "verbal aggression" and a change in condition. But they never revised the resident's behavioral care plan, which had been written weeks earlier to address her tendency to yell at staff and become physical.
The resident, identified only as Resident 1 in inspection records, had moderate cognitive impairment and required assistance with basic daily activities like eating, dressing and personal hygiene. Her December assessment showed she felt "down, depressed, hopeless" and like "a failure" for seven to 11 days during the rating period.
Ten days after the hair-pulling threat, doctors ordered a new antipsychotic medication. The resident's Seroquel dosage was increased to 250 milligrams at bedtime specifically for "anger outburst" related to her schizophrenia.
By February 28, physicians had to adjust the medication again, prescribing Seroquel both as a daily dose and as needed every six hours for agitation. The order specifically cited "agitation related to schizophrenia."
More behavioral problems followed. On March 3, the resident claimed her roommate made "inappropriate comments" toward her. Staff noted in another assessment that the resident "get agitated often" and that "behavioral changes happens frequently." They wrote that "she create situation to be getting extra attention."
Despite these documented escalations over nearly two months, Sharon Care Center never updated the resident's behavior monitoring care plan from its original December version.
Licensed Vocational Nurse 2 admitted during the March inspection that the facility failed to update the behavioral care plan when the resident had documented changes in condition on January 14 and February 24. The nurse acknowledged that care plans help nursing staff "know what the needs of a resident are and ensure safety and quality of life."
The nurse also confirmed that the care plan for Seroquel lacked specific monitoring instructions that staff should have been following.
The facility's Director of Nursing admitted that a care plan should have been developed or updated when the resident showed behavioral changes in January. "The potential could be that staff may miss something that could help with the Resident 1's behavior," the director told inspectors.
The director acknowledged that the behavior care plan should have included details about the specific types of behavior the resident was displaying. For the Seroquel monitoring, the director admitted that interventions must include the specifics the facility was supposed to monitor.
The resident's original care plan from December had outlined general approaches for staff dealing with her verbal outbursts and physical behaviors. It instructed staff to evaluate triggers, remove the resident from stressful environments when needed, and guide her away while "speaking in a calm, reassuring voice."
But as her condition deteriorated and medications were repeatedly adjusted, those generic instructions remained unchanged.
The facility's Minimum Data Set nurse explained during the inspection that care plans must address resident diagnoses, medications and treatments, and must be "initiated and updated if there is a change in conditions." The nurse emphasized that medication interventions should be specific to each drug, including "the exact side effects to observe and when to report."
Sharon Care Center's own policy, revised in December 2024, requires individualized comprehensive care plans that incorporate identified problem areas and build on residents' needs, strengths and preferences. The policy states that assessments are ongoing and care plans must be "reviewed and revised as information about the resident and the resident's condition change."
Federal inspectors cited the facility for failing to provide comprehensive care planning, finding minimal harm with the potential for actual harm to a few residents.
The resident's threats of violence, medication adjustments and documented behavioral escalations over eight weeks created a clear pattern that the facility's static care plan failed to address. Staff acknowledged missing opportunities to implement interventions that might have helped manage her worsening symptoms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sharon Care Center from 2025-03-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SHARON CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on March 12, 2025.
The incident occurred on January 14, 2025, when the resident became "increasingly agitated" because she wanted her medication schedule changed from 9 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.