Pavilion at Sunny Hills: Head Injury Unreported - CA
The incident at The Pavilion at Sunny Hills, a skilled nursing facility at 2222 N. Harbor Blvd., came to light during a complaint inspection on May 26, 2026. What inspectors found was not just a transfer that went wrong, but a chain of decisions by staff that left a resident's possible head injury unmonitored and unrecorded.
The resident, identified in inspection records as Resident 5, was transferred by CNA 5 without a second staff member present. Two-person assistance was required for her mechanical lift transfers. CNA 5 raised her too high, and she struck her head on the headboard. A colleague, CNA 1, later told inspectors she had been notified of the incident and passed that information to the facility's licensed vocational nurse, LVN 2.
The morning after the transfer, the resident appeared upset. Her head hurt.
LVN 2 said she assessed the resident and found no injury. She completed a paper body check. She did not document the incident anywhere in the medical record. She did not call the resident's physician. Her reasoning, as she explained it to inspectors: there was no injury to document, and no injury meant no reason to notify the doctor.
Her own timeline was shaky. LVN 2 initially told inspectors she was notified of the incident on May 4. When inspectors reviewed the resident's medication administration record alongside her during the interview, LVN 2 acknowledged the notification had actually come on May 5, the morning after the incident, when the resident was still reporting head pain.
The social services director learned about the incident the same day, through a different route. On May 5, after a care conference, the resident asked the SSD to stay behind. She told him that CNA 5 had transferred her without help and that she had almost hit her head on the headboard. The SSD passed that report up the chain.
What happened next was nothing.
When inspectors sat down with the Director of Nursing on May 26, she initially said the head-injury protocol did not apply because the resident had been discharged by the time the facility became aware of the incident. Inspectors told her the resident had reported the incident on May 5, while still in the facility. The DON shifted her position. She acknowledged that under those circumstances, the nurse should have notified the physician and monitored the resident for possible injury. She then reviewed the medical record herself and confirmed it contained no documentation of the resident reporting the incident, no physician notification, and no record of any follow-up monitoring.
The DON's own words established the standard her facility failed to meet. If a resident reported hitting her head during a transfer and was still in pain the next day, the licensed nurse should notify the physician and perform neurological checks. That did not happen.
A head strike hard enough to cause pain that persisted through the following morning is not a minor paperwork lapse. Injuries to the head in elderly residents can include bleeding that does not show up in a bedside assessment, damage that worsens over hours. A physician notification would have put a doctor in the decision about whether to monitor or intervene. That decision was made instead by a nurse who concluded, without documentation or physician input, that nothing was wrong.
Inspectors cited the facility for failing to ensure Resident 5 received adequate supervision and assistance to prevent an accident, and for the failure to assess, document, and report the injury appropriately. The deficiency was tagged at a level of minimal harm or potential for actual harm, with few residents affected.
The resident had already been discharged by the time inspectors arrived. Whether she ever received a medical evaluation for the head injury she reported is not reflected in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Pavilion At Sunny Hills from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
THE PAVILION AT SUNNY HILLS in FULLERTON, CA was cited for violations during a health inspection on May 26, 2026.
The incident at The Pavilion at Sunny Hills, a skilled nursing facility at 2222 N.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.