Sharon Care Center had not contacted Resident 1's family members for over a year to discuss her care or progress, according to interviews with family members conducted during a November inspection. The facility failed to inform them that she had developed pressure ulcers or was refusing care, even as her condition deteriorated significantly.
FM 1, a family member, told inspectors that Resident 1 had been in her usual state of health, getting helped out of bed to sit in her wheelchair and socialize with other residents in the dining room. But she gradually stopped these activities, stayed in bed, and developed increased confusion.
The facility's silence broke on November 6, 2025, when staff called FM 2 for the first time to report that Resident 1 was refusing to eat and declining to have an IV inserted for fluid support. The next day, they called FM 1 to say the resident was being sent to GACH hospital for poor oral intake.
What the family found at the hospital shocked them.
"They were both shocked at Resident 1's condition as she appeared to be very skinny and had a wound to her sacrum which was very scary to look at it had reached the bone," according to the inspection report. Hospital staff told them the resident had developed an infection from the wound that had spread to her bloodstream.
The facility's own Director of Nursing confirmed multiple policy violations during the inspection. She acknowledged that when a resident consumes less than 50% of their meals, the physician must be notified after two to three meals. Resident 1 had consumed less than half her meals starting October 28, 2025, and her intake "progressively decreased several times after that," but the physician was never notified about this change in condition.
The nursing director stated that notifying physicians about decreased oral intake is "important for the resident's well-being and for improving PU outcomes." She confirmed that reduced intake could result in dehydration.
Sharon Care Center's own policies required immediate notification of family and physicians when residents experience significant changes in physical, mental, or psychosocial status. The facility's Change in Condition policy, reviewed in December 2024, specifically mandated informing family representatives about "deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications."
The policy also required notification when there was "a need to alter treatment significantly" or "to discontinue or change an existing form of treatment due to adverse consequences."
Another facility policy on hydration and dehydration prevention, reviewed in March 2025, instructed nurses to "assess for signs and symptoms of dehydration during daily care" and stated that "laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration."
FM 1 told inspectors that Resident 1 was confused and unable to make decisions for herself, making family involvement in her care decisions crucial.
The inspection found that the facility violated federal requirements for notifying families and physicians about changes in residents' conditions. The violation was classified as causing minimal harm or potential for actual harm to some residents.
The family's year-long exclusion from knowledge about their relative's declining condition meant they had no opportunity to advocate for different care approaches or make informed decisions about her treatment as pressure ulcers developed and her nutritional status deteriorated to the point of requiring hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sharon Care Center from 2025-11-26 including all violations, facility responses, and corrective action plans.