Pavilion at Sunny Hills: Infection Control Lapse - CA
Inspectors were watching.
The incident happened on the morning of May 26, 2026, at 10:30 a.m., as two certified nursing assistants used a mechanical lift to move Resident 7 from his bed into a wheelchair. The floor mat, used to cushion falls, was propped lengthwise against the left side of the bed and the upper grab bar. Its upper portion was touching the resident's sheets. An inspector took a photograph.
CNA 2 told the inspector he had moved the mat off the floor to clear space for the transfer. He acknowledged that floors and anything placed on them are considered contaminated. He said he should have leaned the mat against the wall instead. He did not dispute what the inspector had seen.
That afternoon, inspectors spoke with the Director of Nursing. She said the same thing: anything on the floor is dirty. The floor mat should not have been placed against the resident's bed. She called it an infection control concern.
That was the full extent of the record.
What the inspection does not contain is any indication of how long the mat had been in that position before inspectors arrived, whether Resident 7 had any open wounds or compromised immune function that would have made contact with contaminated material especially dangerous, or whether this was the first time a mat had been stored this way in this resident's room.
The violation was rated at the lowest level of harm, minimal harm or potential for actual harm, affecting few residents. One resident was identified in the sample of eight. The finding was cited under infection control standards.
Floor mats in nursing homes sit on floors that are walked on by staff, rolled over by wheelchairs and medical equipment, and cleaned on a schedule that does not make them sterile between uses. The floor is treated as a contamination zone in infection control practice precisely because of what accumulates on it. When an object from the floor touches a resident's bedding, whatever is on the floor has a direct path to the resident.
CNA 2 knew that. He said so himself.
The mechanical lift transfer that prompted him to move the mat is a routine procedure in skilled nursing facilities. Residents who require a mechanical lift to move from bed to a wheelchair cannot reposition themselves. Resident 7 was lying in his bed when inspectors arrived. He was present for the entire interaction, the transfer, the mat propped against his sheets, the inspector's questions, the photograph.
The Director of Nursing's confirmation that the mat should not have been there closed the loop on the factual dispute. There was no factual dispute. What remains is a simpler question: in a room where a man who cannot move himself is lying in a bed, a contaminated object was placed against his bedding, and no one in the room corrected it until an inspector walked in.
The Pavilion at Sunny Hills is a skilled nursing facility in Fullerton. The inspection was conducted as a complaint investigation.
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 14, 2026 · Our methodology
THE PAVILION AT SUNNY HILLS in FULLERTON, CA was cited for violations during a health inspection on May 26, 2026.
The floor mat, used to cushion falls, was propped lengthwise against the left side of the bed and the upper grab bar.
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.