Resident 5 was admitted in March 2020 with diabetes, high cholesterol, dementia and difficulty swallowing. A March 2025 medical evaluation indicated the resident lacks capacity to understand and make decisions. By June, assessments showed severely impaired cognition requiring maximum assistance with basic tasks like oral hygiene, dressing and toileting.
The resident is completely dependent on staff for showering.
Certified Nursing Assistant 1 told inspectors on September 11 that Resident 5 "has a long history of spitting" and that she provides the resident with a small trash can next to the bed or wheelchair. The nursing assistant said she reminds the resident to spit into the trash can instead of on the floor.
But when inspectors interviewed the Director of Nursing the same day, she said she was unaware of the resident's spitting episodes.
The nursing director confirmed that Resident 5 should have had a care plan addressing the spitting behavior. She told inspectors she directed staff to provide the resident with a basin during spitting episodes.
Federal regulations require nursing homes to develop comprehensive, person-centered care plans within seven days of completing resident assessments. The facility's own policy, updated in May 2025, states that care plans must include "measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs."
The policy specifically mentions addressing oral care and symptom management based on resident assessments.
Inspectors found no care plan addressing Resident 5's spitting behavior despite the nursing assistant's acknowledgment of its long-term nature. The failure represents a breakdown in the facility's care planning process for a resident who requires extensive daily assistance due to severe cognitive impairment.
The resident has lived at Sunland Post Acute for more than five years. During that time, staff developed care plans for assistance with eating, hygiene, dressing and mobility needs. But the spitting behavior, which required daily management by nursing assistants, went unaddressed in formal care planning.
Federal inspectors classified the violation as having potential for actual harm affecting few residents. The finding indicates systemic gaps in how the facility identifies and addresses resident behaviors requiring intervention.
Sunland Post Acute operates at 8647 Fenwick Street in the San Fernando Valley. The September inspection was conducted in response to a complaint about the facility's care practices.
The violation highlights challenges nursing homes face in caring for residents with dementia-related behaviors. Spitting can create infection control concerns and dignity issues for residents and staff, particularly when occurring in common areas or during meals.
For Resident 5, the lack of a formal care plan meant no systematic approach to managing the behavior, no measurable goals for improvement, and no documentation of interventions that might reduce spitting episodes or their impact on the resident's quality of life.
The nursing assistant's informal approach of providing trash cans and verbal reminders represented individual staff initiative rather than coordinated facility-wide care planning. Without a formal plan, there was no assurance that all staff members would respond consistently to the resident's needs.
The Director of Nursing's lack of awareness about the spitting behavior, despite its long-term nature, suggests communication gaps between frontline staff and management. Such disconnects can result in residents not receiving appropriate interventions for behaviors that affect their daily functioning and dignity.
Federal regulations emphasize person-centered care that addresses each resident's individual needs and preferences. For residents with dementia, this includes managing behavioral symptoms that may stem from their underlying condition, discomfort, or environmental factors.
The inspection found that while Resident 5 received assistance with physical needs like dressing and hygiene, the facility failed to address a behavioral manifestation of the resident's dementia through proper care planning protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunland Post Acute from 2025-09-11 including all violations, facility responses, and corrective action plans.