Sharon Care Center
SHARON CARE CENTER in LOS ANGELES, CA — inspection on March 12, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 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 3/7/25 at 12:01 pm, the MDSN stated that every admission packet of a resident being admitted from General Acute Care Hospital (GACH) must include a PASRR level I and II level II if a resident is determined to have serious mental illness.
The MDSN stated that the facility reviews and ensures that the PASRR is accurate.
The facility initiates another PASRR assessment if it is inaccurate during the first clinical team (Director of Nursing [DON], Social Services, MDSN, Medical Records Director) meeting held within the first 24 hours of the resident ' s admission. MDSN confirmed that Resident 1 should have had a PASRR level II completed due to her schizophrenia diagnosis. A PASRR level II triggers additional support from the Department of Mental Health (DMH).
During a concurrent interview and record review of Resident 1 ' s PASRR level I with the DON on 3/11/25 at 12:20 pm, the DON admitted that the evaluation was inaccurate because question number 10 was not answered which may have prompted that PASRR level II be completed.
The DON admitted that the facility should have reviewed and worked to rectify the inaccuracy of PASRR level I.
The DON admitted that support from the DMH personnel may have assisted with finding the right plan of care to prevent escalation of behaviors.
During a review of the facility's policy and procedure (P&P) titled, BEHAVIOR MANAGEMENT, revised 12/16/2024, the P&P indicated, Resident exhibiting behavioral symptoms will be individually evaluated to determine the behavior.
The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to changes in the Resident's behavior.
The same P&P indicated, staff must ensure that a resident Whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty does not display a pattern of decreased social intervention and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable.
055755 03/12/2025
Sharon Care Center 8167 West Third St.
Los Angeles, CA 90048
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.
055755 03/12/2025
Sharon Care Center 8167 West Third St.
Los Angeles, CA 90048
included:
- 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.
During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] 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.
055755
Form Approved OMB
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
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
055755
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.