Sharon Care Center

F-F645.

During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying conditions affecting the body's metabolism, leading to impaired brain function and potentially symptoms like confusion, memory loss, or coma), schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/18/2024, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 had feelings of feeling down, depressed, hopeless, and feeling bad about herself/she was a failure/let herself or family down seven to 11 days. Resident 1 ' s MDS indicated, Resident 1 required between supervision or touching assistance and partial/moderate assistance for all Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off footwear).

During a review of Resident 1 ' s care plan titled Focus: Resident 1 exhibits verbal behaviors aeb (as evidenced by) yelling at staff and becoming physical with staff members related to: Cognitive loss/Dementia, Psychiatric Disorder(s): Schizophrenia, mood disorder dated 12/10/2024, indicated approaches for staff to evaluate the nature and circumstances (i.e., triggers) of the [verbal behavior] with resident/patient and/or resident representative. Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 055755 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055755 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Care Center 8167 West Third St. Los Angeles, CA 90048

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of Resident 1 ' s care plan titled Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to episodes of paranoia dated 12/17/2024, Provide an Level of Harm - Minimal harm or environment that is conducive to the residents/patients ability to get adequate sleep and maintain potential for actual harm resident's/patient's preferred sleep/wake schedule. Allow time for expression of feelings; provide empathy, encouragement, and reassurance Residents Affected - Few

During a review of Resident 1 ' s Situation Background Assessment and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 1/14/2025 at 11:13 pm, indicated Resident 1 had a change in condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) behavioral symptoms identified as verbal aggression. The SBAR indicated, Patient (Resident 1) became increasingly agitated because she wanted her medication scheduled to be changed from 2100 to 19:30 (9pm to 7:30 pm) Patient (Resident 1) stated, I will pull your hair if you don't give me the medication.

During a review of Resident 1 ' s physician ' s order dated 1/24/2025 indicated, Seroquel oral tablet. Give 250mg by mouth at bedtime for schizophrenia m/b (manifested by) anger outburst.

During a review of Resident 1 ' s physician ' s order dated 2/28/2025 indicated, Seroquel 50 mg oral tablet. Give 1 tablet by mouth every 6 hours as needed for agitation and give 1 tablet by mouth one time a day for schizophrenia aeb (as evidence by) agitation related to schizophrenia.

During a review of Resident 1 ' s SBAR dated 3/3/2025 at 6:30 pm indicated, Resident 1 had alleged that her (Resident 1) roommate said inappropriate comments. The SBAR indicated, Patient (Resident 1) get agitated often or behavioral changes happens frequently, she create situation to be getting extra attention.

During an interview with the Minimal Data Set Nurse (MDSN) on 3/7/2025 at 12:01 pm, MDSN stated that a care plan is a tool to address pt (resident) needs to provide the right care during a resident ' s stay. MDSN stated that all residents must have care plans about their diagnoses, medications, and treatments such as skin care treatments. MDSN stated that care plans must be initiated and updated if there is a change in conditions. Interventions for medications must be specific to each medication such as the exact side effects to observe and when to report.

During a concurrent interview and record review of Resident 1 ' s chart with Licensed Vocational Nurse (LVN) 2 on 3/10/2025 at 9:27 am, LVN 2 stated that a care plan must be initiated when there is a COC or updated when one had already been developed because that is how nursing staff know what the needs of a resident are and ensure safety and quality of life. LVN 2 confirmed that the care plan for Seroquel did not list

the specific interventions nursing staff should have been monitoring. LVN 2 admitted that the behavior monitoring care plan was not updated when Resident 1 had a change in condition on 1/14/2025 and 2/24/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 055755 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055755 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Care Center 8167 West Third St. Los Angeles, CA 90048

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a concurrent interview and record review of Resident 1 ' s chart with the Director of Nursing (DON) on 3/11/2025 at 12:20 pm admitted that a care plan should have been developed/updated when she had Level of Harm - Minimal harm or behavioral changes on 1/14/25 to show what the plan is for the resident. The potential could be that staff potential for actual harm may miss something that could help with the Resident 1 ' s behavior. The DON confirmed admitted that the behavior care plan should have included the types of behavior Resident 1 was presenting. The DON Residents Affected - Few admitted stated that for the Seroquel, the interventions must include the specifics that the facility were monitory as listed in the behavior monitoring.

During a review of the policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE, revised 12/16/2024, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident' s medical, physical, mental and psychosocial needs shall be developed for each resident. The same P&P indicated the following procedures which included:

Each resident ' s comprehensive care plan is designed to:

- Incorporate identified problem areas.

- Build on the resident's individualized needs, strengths, preferences.

Assessments of residents are ongoing and care plans arc reviewed and revised as information about the resident and the resident's condition change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 055755

F-F656.

Findings:

During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying conditions affecting the body's metabolism, leading to impaired brain function and potentially symptoms like confusion, memory loss, or coma), schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/18/2024, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 had feelings of feeling down, depressed, hopeless, and feeling bad about herself/she was a failure/let herself or family down seven to 11 days. Resident 1 ' s MDS indicated, Resident 1 required between supervision or touching assistance and partial/moderate assistance for all Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off footwear).

During a review of Resident 1 ' s Situation Background Assessment and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 1/14/2025 at 11:13 pm, indicated Resident 1 had a change in condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) behavioral symptoms identified as verbal aggression. The SBAR indicated, Patient (Resident 1) became increasingly agitated because she wanted her medication scheduled to be changed from 2100 to 19:30 (9pm to 7:30 pm) Patient (Resident 1) stated, I will pull your hair if you don't give me the medication. The same SBAR indicated that the physician was not yet informed about the COC.

During a review of Resident 1 ' s SBAR dated 3/3/2025 at 6:30 pm indicated, Resident 1 had alleged that her (Resident 1) roommate said inappropriate comments. The SBAR indicated, Patient (Resident 1) get agitated often or behavioral changes happens frequently, she create situation to be getting extra attention. The SBAR did not include any recommendations from the physician

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 055755 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055755 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Care Center 8167 West Third St. Los Angeles, CA 90048

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 During a review of Resident 1 ' s SBAR dated 3/6/2025 at 9:25 am, indicated, Resident 1 was evaluated for Altered Mental Status (AMS). The same SBAR indicated that Resident 1 had personality changes and AMS. Level of Harm - Minimal harm or Resident 1 was sent to Emergency Department (ED) for further evaluation. potential for actual harm

During a review of nursing notes dated 3/6/2025 at 9:26 am indicated, Pt attempted to choke herself with hair Residents Affected - Few bonnet. Assisted by license nurses, 3 CNA's, activities and maintenance director. Removed bonnet and attempted to redirect the pt (Resident 1) . Fire department responded for 5150 (a temporary, involuntary psychiatric hold in California, where a person is taken into custody for up to 72 hours for evaluation and treatment if they are deemed a danger to themselves or others, or are gravely disabled due to a mental illness) followed by LAPD (Pos Angeles Police Department) officers Pt (Resident 1) transferred via 911 (the emergency telephone number in the United States and Canada used to contact police, fire, or ambulance services for immediate help) to GACH.

During a concurrent interview and record review of Resident 1 ' s SBAR for 1/14/2025 with Licensed Vocational Nurse (LVN) 2 on 3/10/2025 at 9:27 am, LVN 2 admitted that there was no documented evidence that the physician was notified about the change. She stated that the physician must be informed about all changes in condition.

During a concurrent interview and record review of Resident 1 ' s SBAR dated 1/14/2025 with the Director of Nursing (DON) on 3/11/2025 at 12:20 pm confirmed that there was no documented evidence that the physician was called and informed. The DON stated that notifying the physician is important because they (physician) will give new orders or instructions on how to handle the behaviors presented.

During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, revised 12/16/2024, the P&P indicated, To ensure residents, family, legal representatives, and physicians are infom1ed of changes in the resident's condition. The same P&P indicated, A Facility must immediately inform the resident, consult with the Resident's physician and/or NP (Nurse Practitioner), and notify, consistent with his/her authority, Resident Representative where there is:

An accident involving the Resident.

A significant change in the Resident's physical, mental, or psychosocial status (that is, a

deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications).

A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new fom1 of treatment); or

A decision to transfer or discharge the Resident from the Center.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 055755 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055755 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Care Center 8167 West Third St. Los Angeles, CA 90048

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45524

Residents Affected - Few Based on observations and record reviews, the facility failed to monitor one of the three sampled residents (Resident 1) by failing to:

1. Update Resident 1 ' s care plan for at risk for physical behavior towards others, after a Change of Condition (COC) on 1/14/2025 and 2/24/2025.

2. create an individualized and specific interventions for quetiapine fumarate (Seroquel- an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) and schizophrenia.

This failure resulted in the escalation of behaviors requiring Resident 1 to be admitted to General Acute Care Hospital (GACH) on 3/6/2025.

Findings:

Cross reference