Sharon Care Center

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

standards of practice for problem areas and conditions. The P&P indicated Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change.

1. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was

initially admitted to the facility on [DATE REDACTED] with diagnosis of COPD, then readmitted on [DATE REDACTED] with diagnosis of acute respiratory failure with hypoxia (low levels of oxygen in your body tissues).

During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had intact cognitive (ability to think, remember and reason) the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 2 was independent (Resident completes the activity by themself with no assistance from

a helper) for eating, oral hygiene, upper body dressing, personal hygiene, rolling left and right, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 2 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity.

Assistance may be provided throughout the activity or intermittently) for toileting, lower body dressing, putting on taking off footwear, sit to stand, toilet and shower transfer.

During a review of Resident 2's Care Plan, dated 5/30/2025, the Care Plan indicated administer oxygen as prescribed for COPD. No revisions to the Care Plan for diagnosis of COPD were found after Resident 2 had returned from the hospital on [DATE REDACTED].

During an interview with RNS 2, on 11/19/2025 at 12:34 PM the RNS 2 stated the Care Plan had not been updated after Resident 2's return from the hospital. The RNS stated failure to revise the Care Plan placed Resident 2 at risk for unmet needs and inadequate management of respiratory status.

During an interview with the DON, on 11/19/2025 at 2:14 PM the DON stated it was important to update and revise Care Plans as needed, following a change in condition, and quarterly in order to guide nurses to provide the care residents need and failure to do so places residents at risk for unmet needs and miscommunication among licensed nurses.

During a review of the facility's P&P titled Care Plan Comprehensive, dated 12/16/2024, the P&P indicated

the facility is responsible for evaluation and updating of care plans when there has been a significant change in the resident's condition, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure licensed nurses disposed of used tube feeding formula and tubing, discarded remaining formula, and tubing per facility policy for one of three resident (Resident 3).This failure placed Resident 3 at risk for contamination of enteral formula, bacterial growth, aspiration (The accidental breathing in of food or fluid into the lungs, potentially causing pneumonia or other lung problems), gastrointestinal infection, sepsis (systemic infection), and compromised nutritional status.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE REDACTED] with diagnosis of dysphagia (Difficulty or discomfort in swallowing), and gastrostomy (G-tube- tube inserted through the belly that brings nutrition directly to the stomach), COPD, and respiratory failure.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 8/20/2025, indicated Resident 3 had severely impaired cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 3 was dependent (Helper does ALL of

the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and rolling left and right. The MDS indicated Resident 3 had a feeding tube (a way of delivering nutrition directly to your stomach or small intestine) to deliver nutrition. During a concurrent observation and interview on 11/19/2025 at 1:18 PM with

the Director of Nursing (DON) in Resident 3's room, the DON verified that Resident 3's tube feeding was connected to an empty formula bottle and a bag with water. No labels were present on the tubing, formula bottle, nor the bag of water to indicate when these were first used. The DON stated the tubing should be dated and initiated by the staff who hung the formula and tubing with a date of when these were administered and should be disposed of once they are turned off. The DON stated failure to discard the tubing and formula and failing to label the feeding supplies placed Resident 3 at risk for inaccurate monitoring of nutritional intake, aspiration, and increased risk of infection. During an interview with Licensed Vocational Nurse (LVN) 1, on 11/19/2025 at 1:43 PM the LVN1 stated she turned off Resident 3's feeding in

the morning but failed to dispose of the feeding tubing, empty bottle of formula, and acknowledged she should have discarded the tubing and formula according to facility policy. During a review of the facility's policy and procedures (P&P) titled Enteral Feedings Safety Precautions, dated 12/16/2024, the P&P indicated, to ensure the safe administration of enteral nutrition, prevent errors in administration by labeling enteral nutrition with date and time formula was prepared, and on the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

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