Sunset Manor Conv Hosp

F-F689

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024 with diagnoses that included type II Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition when the heart is not able to pump enough blood and oxygen to the body's organs) and respiratory failure (a condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the resident by a physician) dated 9/17/2024, the H&P indicated Resident 1 was non-verbal and did not have the capacity to make medical decisions.

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 1 had unclear speech and severely impaired cognition (thinking, reasoning, or remembering for daily decision making). The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) for toileting, showering, dressing and chair/bed-to-chair transfers.

During an observation of Resident 1's right palm, in Resident 1's room and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 1/3/2025 at 11:29 am, Resident 1's right palm had seven stitches between the thumb and the index finger. LVN 1 stated, Resident 1 was sent to GACH 1 on 12/17/2024 due to a cut to the right hand from Resident 1's bed remote control coil line. LVN 1 stated, the outer hard plastic layer of Resident 1's bed remote control coil line was broken, and part of the coil was pointing out. LVN 1 stated, when CNA 2 turned and repositioned Resident 1, Resident 1 grabbed onto the sharp broken part (plastic) of the bed remote control coil line, and Resident 1 sustained a laceration of Resident 1's right hand/palm. LVN 1 stated, staff (in general) need to ensure Resident 1's equipment was in good condition to prevent injury to Resident 1. LVN 1 stated, maintenance staff need to routinely check all devices and equipment to ensure the equipment and devices were in good condition and working properly for resident's safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 055104 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055104 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

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 0908 During an interview with the Maintenance Assistant (MA) on 1/3/2025 at 12 pm, the MA stated, the MA did

an investigation on 12/17/2024 after Resident 1 sustained a right-hand laceration. The MA stated, Resident Level of Harm - Minimal harm or 1's bed remote control coil line was broken. The MA stated the inside of the electric wire was exposed, and potential for actual harm the outer layer/hard plastic was peeled off, forming a sharp pointed edge. The MA stated, there was blood stain on the broken part of Resident 1's bed remote control coil. The MA stated, checking the bed remote Residents Affected - Few control was not part of the Maintenance Department's routine task since MA started working at the facility nine months ago and the Maintenance Department would only check the bed remote control upon request.

The MA stated, checking the bed remote control was added to the Maintenance Department's routine task

after the incident with Resident 1, who sustained a laceration of the inner right hand on 12/17/2024. The MA stated it was important to check all resident's equipment routinely including the bed remote control to ensure resident's safety and to prevent injury to the residents. The MA stated, if the Maintenance Department performed a routine check and found the broken bed control coil line earlier, Resident 1's injury could have been prevented.

During an interview with the facility's Director of Nursing (DON) on 1/3/2025 at 1:17 pm, the DON stated, it was important to routinely check all medical devices and equipment and to keep them in good condition for resident's safety. The DON stated, Resident 1's injury (laceration to the right inner hand) could be avoided if

the facility maintained its equipment in good condition.

During a review of the facility's P&P titled, Preventive Maintenance Program, dated 12/19/2022, the P&P indicated A preventive maintenance program shall be developed and implemented to ensure the provision of

a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The P&P indicated The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 055104

F-F908

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024 with diagnoses that included type II Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition when the heart is not able to pump enough blood and oxygen to the body's organs) and respiratory failure (a condition when the lungs cannot get enough oxygen into the blood).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 6 055104 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055104 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

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 0689 During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the resident by a physician) dated 9/17/2024, the H&P indicated Resident 1 was non-verbal and did not have the Level of Harm - Actual harm capacity to make medical decisions.

Residents Affected - Few During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 1 had unclear speech and severely impaired cognition (thinking, reasoning, or remembering for daily decision making). The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) for toileting, showering, dressing and chair/bed-to-chair transfers.

During a review of Resident 1's Progress Notes (PN), dated 12/17/2024, timed at 5 am, the PN indicated Resident 1 sustained an inner right-hand cut (laceration) when Resident 1 held onto the right bed side rail while being cleaned and turned by CNA 2.

During a review of Resident 1's PN, dated 12/17/2024, timed at 5:46 am, the PN indicated Resident 1 had an open cut/wound on the inner right hand. The PN indicated Resident 1's right hand wound was acquired in the facility and measured 2 cm in length by 0.2 cm in width and 0.2 cm in depth.

During a review of Resident 1's Physician's Order (PO) dated 12/17/2024 (untimed), the PO indicated to transfer Resident 1 to GACH 1 due to right hand cut.

During a review of Resident 1's PN dated 12/17/2024, timed at 10:45 am, the PN indicated Resident 1 was transferred to GACH 1 due to a cut on the right hand.

During a review of GACH 1's Emergency Department Note (EDN) dated 12/17/2024, the EDN indicated Resident 1 had a right-hand laceration and received laceration repair. The EDN indicated Resident 1's right hand laceration was closed with seven stitches.

During a review of Resident 1's PN dated 12/17/2024, timed at 6:20 pm, the PN indicated Resident 1 was readmitted back to the facility from GACH 1 after treatment of Resident 1's laceration to the right palm (the grasping side of the hand) of the hand. The PN indicated Resident 1 had six stitches along the right thumb with ragged edges and one stitch on the base of the index finger with skin tear.

During an observation of Resident 1's right hand in Resident 1's room on 1/3/2025 at 11:24 am, Resident 1 was lying in bed with eyes closed. Resident 1's right hand was wrapped with dry bandage roll (a long, rolled-up piece of absorbent material used to cover wounds, apply pressure, and secure dressings).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 055104 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055104 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

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 0689 During an observation of Resident 1's right palm, in Resident 1's room and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 1/3/2025 at 11:29 am, Resident 1's right palm had seven stitches Level of Harm - Actual harm between the thumb and the index finger. LVN 1 stated, Resident 1 was sent to GACH 1 on 12/17/2024 due to a cut to the right hand from Resident 1's bed remote control coil line. LVN 1 stated, the outer hard plastic Residents Affected - Few layer of Resident 1's bed remote control coil line was broken, and part of the coil was pointing out. LVN 1 stated, when CNA 2 turned and repositioned Resident 1, Resident 1 grabbed onto the sharp broken part (plastic) of the bed remote control coil line, and Resident 1 sustained a laceration of Resident 1's right hand/palm. LVN 1 stated, staff (in general) need to ensure Resident 1's equipment was in good condition to prevent injury to Resident 1. LVN 1 stated, maintenance staff need to routinely check all devices and equipment to ensure the equipment and devices were in good condition and working properly for resident's safety.

During an interview with the Maintenance Assistant (MA) on 1/3/2025 at 12 pm, the MA stated, the MA did

an investigation on 12/17/2024 after Resident 1 sustained a right-hand laceration. The MA stated, Resident 1's bed remote control coil line was broken. The MA stated the inside of the electric wire was exposed, and

the outer layer/hard plastic was peeled off, forming a sharp pointed edge. The MA stated, there was blood stain on the broken part of Resident 1's bed remote control coil. The MA stated, checking the bed remote control was not part of the Maintenance Department's routine task since MA started working at the facility nine months ago. The MA stated, the Maintenance Department would only check the bed remote control upon request. The MA stated, checking the bed remote control was added to the Maintenance Department's routine task after the incident with Resident 1, who sustained a laceration of the inner right hand on 12/17/2024. The MA stated, it was important to check all resident's equipment routinely including the bed remote control to ensure resident's safety and to prevent injury to the residents. The MA stated, if the Maintenance Department performed a routine check and found the broken bed control coil line earlier, Resident 1's injury could have been prevented.

During a concurrent review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals who work together to provide patient care), Progress Note dated 12/17/2024, timed at 2:27 pm, and an

interview with the facility's Director of Nursing (DON) on 1/3/2025 at 1:17 pm, the IDT Progress Note indicated on 12/17/2024 around 5 am, Resident 1 was being turned and changed by CNA 2 and CNA 2 saw Resident 1 holding onto the siderail on the right side of the bed with bloody open cut in the inner right hand between Resident 1's thumb and index finger. The IDT Progress Note indicated Resident 1's bed control coil line was damaged with the hard plastic sticking out. The DON stated Resident 1 grabbed onto Resident 1's damaged/broken bed coil line and sustained an injury on Resident 1 right hand. The DON stated, it was important to routinely check all medical devices and equipment and to keep them in good condition for resident's safety. The DON stated, Resident 1's injury (laceration to the right inner hand) could be avoided if

the facility maintained its equipment in good condition.

During an interview with the facility's Administrator (ADM) on 1/3/2025 at 3:01 pm, the ADM stated CNA 2 was terminated. The ADM and Surveyor 1 called CNA 2 for a telephone interview and CNA 2 did not answer

the phone call.

During a review of the facility's P&P titled, Safe and Homelike Environment, dated 12/19/2022, the P&P indicated The facility will provide a safe, clean, comfortable, and homelike environment. The P&P indicated

This includes ensuring that the resident can receive care and services safely and that the physical layout of

the facility maximizes resident independence and does not pose a safety risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 055104 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055104 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

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 0689 During a review of the facility's P&P titled, Preventive Maintenance Program, dated 12/19/2022, the P&P indicated A preventive maintenance program shall be developed and implemented to ensure the provision of Level of Harm - Actual harm a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The P&P indicated The maintenance director is responsible for developing and maintaining a schedule of maintenance Residents Affected - Few services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 055104 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055104 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 40037 potential for actual harm Based on observation, interview, and recorded review, the facility failed to maintain the resident's bed remote Residents Affected - Few control coil line (coiled remote-control cord) in safe operating condition for one of three sampled residents (Resident 1). The hard plastic covering of Resident 1's bed remote control coil line was damaged and pointed out.

This failure resulted in a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's inner right hand between the thumb and index finger (also known as the pointer finger, or first finger) measuring 2 centimeters (cm-unit of measurement) in length, by 0.2 cm in width and by 0.2 in depth.

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