The Pavilion At Sunny Hills

F-F656, example #1.

47746

2. On 4/21/25 at 0828 hours, during the initial tour of the facility, Resident 80 was observed with a midline catheter to the LUA with the dressing dated 4/17/25. Resident 80 stated he was receiving two different types of antibiotic medications in the facility due to a bone infection to his left foot.

Medical record review for Resident 80 was initiated on 4/21/25. Resident 80 was admitted to the facility on [DATE REDACTED].

Review of Resident 80's Admission Body Check dated 3/12/25, showed the resident had a RUA PICC line with two lumens (channels or tubes inside the PICC line).

Review of Resident 80's H&P examination dated 3/13/25, showed Resident 80 had the capacity to understand and make decisions.

Review of Resident 80's plan of care showed a care plan problem dated 3/21/25, addressing the resident's RUA PICC line. The interventions included to measure the IV lines on admission and after dressing change, and the arm circumference three inches above the insertion site every seven days during the day shift (0700 to 1500 hours).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0694 Review of Resident 80's MAR for March and April 2025 showed a physician's order dated 3/13/25, to measure the IV lines on admission and after dressing change, and the arm circumference three inches Level of Harm - Minimal harm or above the insertion site every seven days during the day shift. The MAR showed the order was discontinued potential for actual harm on 4/16/25. Further review of Resident 80's MAR for March and April 2025 showed the licensed nurses signed the MAR; however, the MAR failed to show the measurements of the arm circumference and external Residents Affected - Few catheter length for the PICC line on 3/13, 3/20, 3/27, 4/3, and 4/10/25.

Further review of Resident 80's medical record failed to show the baseline measurements of the arm circumference and external catheter length were obtained upon admission to the facility.

On 4/23/25 at 0938 hours, an observation and concurrent interview was conducted with Resident 80. Resident 80 was observed with a midline catheter to the LUA. Resident 80 stated he accidentally pulled out

the previous IV access on his RUA when he was putting on his sweater sleeve but the IV access was changed to a midline catheter on 4/17/25.

On 4/23/25 at 0958 hours, an interview and medical record review was conducted with RN 1. RN 1 verified Resident 80 had a RUA PICC line upon admission to the facility, but it was changed to a midline catheter on 4/17/25.

On 4/23/25 at 1108 hours, an interview and medical record review was conducted with the DON. When asked, the DON stated the RNs were responsible to measure and document the arm circumference and external catheter length upon the resident's admission to the facility, then weekly when the resident had a PICC line or a midline catheter. The DON verified Resident 80's MAR for March and April 2025 did not show

the measurements of the resident's arm circumference and external catheter length of the PICC line for the above dates. The DON further verified the baseline measurements of Resident 80's RUA PICC line external catheter length and arm circumference were not obtained upon Resident 80's admission to the facility.

On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48882 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few three of four sampled residents (final sampled residents, Residents 109, 143, and 155) reviewed for respiratory care were provided with the appropriate respiratory care and services when:

* The facility failed to ensure Resident 109 received the continuous oxygen therapy via the nasal cannula (flexible tube to deliver oxygen into the nose) as per the physician's order. In addition, the facility failed to ensure the nasal cannula oxygen tubing was not touching the floor mat on the ground.

* Resident 143's nebulizer oxygen tubing was improperly stored, having been found lying on top of a sock on

the resident's end table.

* The facility failed to ensure a physician's order was obtained for Resident 155's use of oral suctioning equipment. Additionally, the facility failed to ensure Resident 155's oral suctioning equipment was labeled when changed.

These failures had the potential to affect the respiratory health and well-being of these residents in the facility.

Findings:

Review of the facility's P&P titled Respiratory Care Oxygen Therapy revised 1/2025 showed the facility provides competent staff to administer oxygen therapy through various types of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheter, oxygen canisters, cylinders, or concentrators. A physician order shall be maintained in the medical record including parameters of oxygen administration and indications for use. The medical record reflects ongoing assessment of the resident's respiratory status and response to oxygen therapy. The staff should document, based on current professional standards of practice, the assessment and monitoring of the resident's respiratory condition, including response to therapy provided, and any changes in the respiratory condition

1. On 4/21/25 at 0852 hours, Resident 109 was observed in bed, with the nasal cannula oxygen tubing inside

a clear plastic bag. Resident 109 was not observed receiving the oxygen.

Medical record review for Resident 109 was initiated on 4/21/25. Resident 109 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED]. Resident 109 had the diagnosis of acute respiratory failure with hypoxia and acute pulmonary edema.

Review of Resident 109's Order Summary Report dated 4/23/25, showed a physician's order dated 3/24/25, to administer continuous oxygen at two to three liters per minute via the nasal cannula, may titrate to maintain SPO2 (peripheral oxygen saturation, a measurement of the amount of oxygen in a person's blood) greater than 91 percent (%) and to monitor and document the oxygen saturation level every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0695 Review of Resident 109's plan of care showed a care plan problem dated 3/24/25, addressing Resident 109's episode of desaturation, shortness of breath, and altered level of consciousness on 3/24/25. The Level of Harm - Minimal harm or interventions included to administer the oxygen continuously at two to three liters per minute via the nasal potential for actual harm cannula and to monitor and document the oxygen saturation level every shift.

Residents Affected - Few On 4/23/25 at 0846 hours, Resident 109 was observed with the following:

- The oxygen nasal cannula was on the right side of Resident 109's bed between the bedrail and the mattress and connected to the oxygen concentrator machine. The oxygen concentrator machine was on and set at two liters per minute; and

- The oxygen nasal cannula tubing was observed touching the floor mat on the ground.

LVN 5 was observed at the doorway to Resident 109's room, preparing for the morning medication administration.

On 4/23/25 at 0918 hours, Resident 109 was observed in bed with the oxygen nasal cannula on the right side of the bed, near the bed rail, and the oxygen nasal cannula tubing was observed touching the floor mat

on the ground.

On 4/23/25 at 0921 hours, an observation, interview, and concurrent medical record review for Resident 109 was conducted with LVN 5. LVN 5 was observed exiting Resident 109's room and pushing the medication cart to another room. LVN 5 stated she had completed her morning medication administration for the three residents in Resident 109's room, including Resident 109. When asked about Resident 109's oxygen therapy, LVN 5 reviewed Resident 109's medical record and stated Resident 109 was currently receiving continuous oxygen at two to three liters per minute via the nasal cannula. When asked about Resident 109's current oxygen setting, LVN 5 stated she did not check the oxygen setting during the medication administration for Resident 109. LVN 5 verified the above findings. When asked, LVN 5 stated she did not pay attention as to whether Resident 109's nasal cannula was properly on him or if the nasal cannula oxygen tubing was touching the floor mat. LVN 5 was observed replacing the oxygen nasal cannula tubing with a new tubing and placed the new nasal cannula on Resident 109. LVN 5 checked Resident 109's oxygen saturation level and stated his oxygen saturation level was at 88-89%. When asked if LVN 5 could hear the oxygen concentrator machine during the medication administration, LVN 5 stated she was able to hear the oxygen concentrator machine was on, but she did not check to see if the nasal cannula was properly on Resident 109. LVN 5 further stated she should have checked.

On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated for the care of a resident on oxygen therapy, the licensed nurses were expected to administer the oxygen as per the physician's order. The DON stated when making rounds and during the administration of medications, the licensed nurse was responsible for checking the placement of the nasal cannula to ensure it was properly placed on the resident. The DON further stated in addition to checking for the proper placement of the oxygen tubing, the licensed nurses were responsible for checking to ensure the oxygen tubing was not touching the ground.

On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0695 2. Medical record review for Resident 143 was initiated on 4/21/25. Resident 143 was admitted to the facility

on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 143's Order Summary Report showed a physician's order dated 2/11/25, to administer ipratropium-Albuterol (medication to relax muscles around the lungs' airways, to ease breathing) inhalation Residents Affected - Few solution 0.5-2.5 mg per 3 ml inhalation solution, every four hours as needed for shortness of breath and/or wheezing.

On 4/21/25 at 1019 hours, an observation and concurrent interview was conducted with Resident 143 and LVN 3. A nebulizer attached to an oxygen tubing was observed at Resident 143's bedside. The open end of

the oxygen tubing was observed lying on top of a sock on Resident 143's end table. Resident 143 stated she had not handled the oxygen tubing. LVN 3 verified the findings and stated she would discard the oxygen tubing for infection control.

47476

3. On 4/21/25 at 1436 hours, an observation and concurrent interview was conducted with CNA 4 in Resident 155's room. CNA 4 stated Resident 155 did her own oral care and the licensed nurses would suction her. The oral suctioning equipment, including the Yankauer suction tip, suction tubing, and suction canister were observed not labeled with the date and time it was last changed.

On 4/21/25 at 1556 hours, an observation and concurrent interview was conducted with LVN 9 in Resident 155's room. LVN 9 stated Resident 155 performed the oral suctioning by herself and the facility staff changed the canister, tubing, and Yankauer suction tip once a week. The oral suctioning equipment, including the Yankauer suction tip, suction tubing, and suction canister were observed not labeled with the date and time it was last changed. LVN 9 verified the above findings and stated usually the Yankauer suction tip and tubing would be labeled with a date. LVN 9 stated the facility staff replaced the tubing every Sunday; however, LVN 9 verified he did not know when Resident 155's tubing and Yankauer suction tip were last changed. LVN 9 stated the facility staff labeled the tubing with the date it was changed to prevent infections.

Medical record review for Resident 155 was initiated on 4/21/25. Resident 155 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 155's H&P examination dated 4/4/25, showed Resident 155 had the capacity to understand and make decisions.

Review of Resident 155's Assessment Summary dated 4/4/25, showed the resident's change in condition involving throat congestion. The assessment section showed Resident 155 complained of throat congestion, oral suction was provided as tolerated, and no complaints of nasal congestion. The NP was made aware and ordered STAT chest x-ray, laboratory tests, and an inhaler medication every six hours for shortness of breath.

Review of Resident 155's Order Summary Report dated 4/23/25, showed a physician's order dated 4/22/25, to suction orally with the Yankauer suction tip as needed for increased oral secretions/oral care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0695 On 4/22/25 at 1515 hours, an interview was conducted with Resident 155. Resident 155 stated she used the oral suction by herself for excessive phlegm in her throat. Level of Harm - Minimal harm or potential for actual harm On 4/24/25 at 0957 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 155 performed oral care by herself. LVN 1 was informed Resident 155 was observed Residents Affected - Few with the oral suctioning equipment at the bedside since 4/21/25. LVN 1 verified Resident 155 was started on oral suctioning on 4/4/25. LVN 1 stated the resident needed a physician's order for oral suctioning. LVN 1 verified Resident 155 had no physician's order for oral suctioning until 4/22/25.

On 4/28/25 at 0851 hours, an interview and concurrent medical record review was conducted with the DON and Nurse Consultant. The DON and Nurse Consultant were informed and acknowledged the above findings. The DON verified Resident 155 had no physician's order for the oral suctioning until 4/22/25. The DON stated the suctioning tubing and canister should be labeled with a date and time and would be changed out weekly, or as needed if soiled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48882 potential for actual harm Based on interview, medical record review, and facility P&P review, the facility failed to provide the Residents Affected - Few appropriate pain management for two of two final sampled residents (Residents 18 and 69) reviewed for pain management.

* The facility failed to accurately document the monitoring of pain for Residents 18 and 69 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Residents 18 and 69 prior to the administration of the pain medications as per the physician's order. These failures had the potential to put Residents 18 and 69 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Findings:

Review of the facility's P&P titled Pain Assessment and Management revised 1/2025 showed the facility provides pain management to residents who require such services, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Strategies for the prevention and management of pain may include but are not limited to the following: developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both.

1.a. Medical record review for Resident 18 was initiated on 4/21/25. Resident 18 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 18's MDS assessment dated [DATE REDACTED], showed Resident 18 was cognitively intact and coded for the use of an opioid (narcotic pain medication) medication.

Review of Resident 18's Order Summary Report for April 2025 showed the following physician's orders:

- dated 6/25/24, to monitor Resident 18's level of pain every shift, using the 0-10 pain scale as follows: 0= no pain, 1-3= mild pain, 4-6= moderate pain, and 7-10= severe pain.

- dated 6/25/24, to administer acetaminophen (analgesic medication) 325 mg two tablets by mouth every six hours as needed for mild pain, pain levels of 1 to 3; not to exceed three grams of acetaminophen in 24 hours from all sources.

- dated 9/24/24, for the use of Norco (narcotic opioid medication), to document the non-pharmacological approach attempted prior to the administration of pain medication every shift; and to document as follows: 1. Repositioning; 2. Dim Light/Quiet Environment; 3. Hot/Cold Application; 4. Relaxation Techniques; 5. Distraction; 6. Music; 7. Other.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0697 - dated 10/28/24, for the use of acetaminophen, to document the non-pharmacological approach attempted prior to the administration of pain medication, every shift; and to document as follows: 1. Repositioning; 2. Level of Harm - Minimal harm or Dim light/Quiet Environment; 3. Hot/Cold Application; 4. Relaxation techniques; 5. Distraction; 6. Music; 7. potential for actual harm Other.

Residents Affected - Few - dated 3/31/25, to administer hydrocodone-acetaminophen (narcotic opioid medication) 5-325 mg one tablet by mouth every four hours as needed for moderate pain (pain levels of 4 to 6).

- dated 3/31/25, to administer hydrocodone-acetaminophen 5-325 mg two tablets by mouth every four hours as needed for severe pain (pain levels of 7 to 10).

Review of Resident 18's plan of care showed a care plan problem dated 6/26/24, addressing Resident 18's risk for pain. The interventions included to administer the acetaminophen and Norco medication as ordered; and to provide the resident with reassurance that pain was time limited; and to encourage the resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultrasound.

Review of Resident 18's MAR for April 2025 showed Resident 18 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for moderate pain (pain levels of 4 to 6) on the following dates and times when the resident's pain level was not within the pain levels of 4 to 6 as ordered:

- On 4/2/25 at 1047 hours, for a pain level of 8.

- On 4/10/25 at 2350 hours, for a pain level of 8.

- On 4/22/25 at 0856 and 2109 hours, for a pain level of 8.

b. Review of Resident 18's MAR from April 2025 showed Resident 18 was administered the following medications on the following dates, times, and pain levels:

* Resident 18's was administered the acetaminophen medication 325 mg two tablets by mouth every six hours as needed for mild pain (pain levels of 1 to 3):

- On 4/2/25 at 2300 hours, for a pain level of 3.

- On 4/15/25 at 1903 hours, for a pain level of 2.

- On 4/16/25 at 2053 hours, for a pain level of 2.

* Resident 18 was administered the hydrocodone-acetaminophen medication 5-325 mg one tablet by mouth every four hours as needed for moderate pain (pain levels of 4 to 6):

- On 4/6/25 at 0630 hours, for a pain level of 5.

- On 4/18/25 at 0945 hours, for a pain level of 4.

- On 4/22/25 at 0856 and 2109 hours, for a pain level of 8.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0697 However, review of Resident 18's MAR for April 2025 to document the monitoring of the resident's pain level showed the licensed nurses documented Resident 18's pain level was assessed as 0 for no pain for the Level of Harm - Minimal harm or following dates and shifts: potential for actual harm - on 4/2/25, for the night shift; Residents Affected - Few - on 4/6/25, for the night shift;

- on 4/15/25, for the evening shift;

- on 4/16/25, for the evening shift;

- on 4/18/25, for the morning shift; and

- on 4/22/25, for the morning and evening shifts.

Additionally, further review of Resident 18's MAR for April 2025 showed the non-pharmacological approach attempted prior to the administration of the acetaminophen and Norco pain medications were documented as 0 from 4/1 to 4/22/25 for the day, evening, and night shifts.

On 4/23/25 at 1433 hours, an interview and concurrent medical record review for Resident 18 was conducted with LVN 7. LVN 7 stated when pain was reported, the resident's pain would be assessed and the non-pharmacological pain interventions would be implemented and documented in the MAR. LVN 7 stated if

the non-pharmacological pain interventions were effective, then the pain medication would not be needed; but if the non-pharmacological pain interventions were not effective, then the pain medication would be administered as per the physician's order and within the ordered parameters. LVN 7 reviewed Resident 18's medical record and verified the above findings. LVN 7 stated if the pain medication was administered, the non-pharmacological intervention should not be documented as 0.

On 4/28/25 at 1046 hours, an interview and concurrent medical record review for Resident 18 was conducted with the DON. The DON reviewed Resident 18's medical record and verified the above findings.

2. a. Medical record review for Resident 69 was initiated on 4/21/25. Resident 69 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 69's H&P examination dated 12//23/24, showed Resident 69 had no capacity to understand and make decisions.

Review of Resident 69's Order Summary Report for April 2025 showed the following physician's orders:

- dated 10/9/23, to monitor Resident 69's level of pain every shift, using the 0-10 pain scale as follows: 0= no pain, 1-3= mild pain, 4-6= moderate pain, and 7-10= severe pain.

- dated 12/15/23, for the use of the acetaminophen-codeine (narcotic pain medication), to document the non-pharmacological approach attempted prior to the administration of the pain medication every shift; and to document as follows: 1. Repositioning; 2. Dim Light/Quiet Environment; 3. Hot/Cold Application; 4. Relaxation Techniques; 5. Distraction; 6. Music; and 7. Other.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0697 - dated 2/6/25, to administer acetaminophen-codeine 300-30 mg one tablet by mouth every four hours as needed for mild pain, pain levels of 1 to 3; not to exceed three grams of acetaminophen in 24 hours from all Level of Harm - Minimal harm or sources. potential for actual harm

Review of Resident 69's plan of care showed a care plan problem dated 10/11/23, addressing Resident 69's Residents Affected - Few risk for pain. The interventions included to administer the acetaminophen with codeine pain medication as ordered and to offer the non-pharmacological interventions for pain (repositioning, dim lighting, calm and quiet environment, minimal stimulation, etc.).

Review of Resident 69's MAR for April 2025 showed Resident 69 was administered the acetaminophen-codeine 300-30 mg one tablet by mouth every four hours as needed for mild pain (pain levels of 1 to 3) on the following dates and times when the resident's pain level was not within the pain levels of 1 to 3 as ordered:

- On 4/1/25 at 1120 hours, for a pain level of 0.

- On 4/7/25 at 1450 hours, for a pain level of 0.

- On 4/15/25 at 1130 hours, for a pain level of 0.

- On 4/21/25 at 2158 hours, for a pain level of 7.

b. Review of Resident 69's MAR for April 2025 showed Resident 69 was administered the acetaminophen-codeine 300-30 mg one tablet by mouth every four hours as needed for mild pain (pain levels of 1 to 3) on the following dates and times:

- On 4/2/25 at 0848 hours, for a pain level of 3.

- On 4/3/25 at 1336 hours, for a pain level of 3.

- On 4/4/25 at 0200 hours, for a pain level of 3.

- On 4/5/25 at 0806 hours, for a pain level of 3.

- On 4/8/25 at 0438 hours, for a pain level of 3.

- On 4/9/25 at 0100 hours, for a pain level of 3.

- On 4/10/25 at 1235 hours, for a pain level of 3.

- On 4/11/25 at 1338 hours, for a pain level of 3.

- On 4/14/25 at 1340 hours, for a pain level of 1.

- On 4/16/25 at 0040 and 1251 hours, for a pain level of 3.

- On 4/17/25 at 1300 hours, for a pain level of 3.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0697 - On 4/19/25 at 1805 hours, for a pain level of 3.

Level of Harm - Minimal harm or - On 4/22/25 at 0200 hours, for a pain level of 3. potential for actual harm - On 4/24/25 at 0230 hours, for a pain level of 3. Residents Affected - Few However, review of Resident 69's MAR for April 2025 for the monitoring of the resident's pain level showed

the licensed nurses documented Resident 69's pain level was 0 for no pain for the following dates and shifts:

- on 4/2 and 4/3/25, for the day shift;

- on 4/4/25. for the night shift;

- on 4/5/25, for the day shift;

- on 4/8 and 4/9/25; for the night shift;

- on 4/10, 4/11, and 4/14/25, for the day shift;

- on 4/16/25, for the night shift;

- on 4/17/25, for the day shift;

- on 4/19/25, for the evening shift; and

- on 4/22 and 4/24/25, for the night shift.

Additionally, further review of Resident 69's MAR for April 2025 showed the non-pharmacological approach attempted prior to the administration of the acetaminophen-codeine medication was documented as 0 on the following dates and shifts:

- for the day shift: on 4/2, 4/3, 4/5, 4/10, 4/14, 4/16, and 4/17/25,

- for the evening shift: on 4/19 and 4/21/25,

- for the night shift: 4/3, 4/7, 4/8, 4/15, 4/21, and 4/23/25.

On 4/24/24 at 1039 hours, an interview and concurrent medical record review for Resident 69 was conducted with LVN 3. LVN 3 stated the non-pharmacological pain interventions were implemented and documented prior to the administration of the pain medications. LVN 3 stated if the non-pharmacological pain interventions were effective, then the pain medication would not be needed. LVN 3 reviewed Resident 69's medical record and verified the above findings. LVN 3 stated the pain medication should be administered as per the physician's order and within the pain parameters. LVN 3 further stated if the pain medication was administered, then the non-pharmacological intervention should be documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0697 On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated if the pain medication was administered to the resident, the non-pharmacological interventions for pain should be implemented and Level of Harm - Minimal harm or documented in the MAR; and if the non-pharmacological interventions for pain were ineffective, then the potential for actual harm licensed nurse should administer the pain medication as per the physician's orders. The DON stated the purpose of the pain monitoring was to track the resident's pain and to see if there was a trend in the Residents Affected - Few resident's pain. The DON stated the monitoring of pain should be documented accurately. The DON stated if

the pain medication was administered to the resident during the shift, then there should be a pain level documented for the monitoring of pain for that shift in the MAR. The DON stated if the resident reported pain

after the licensed nurse documented no pain, the DON expected the licensed nurses to update the pain monitoring for that shift in the MAR to accurately reflect the resident's pain monitoring.

On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47474

Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure

the pharmaceutical services were provided to meet the needs for one of 35 sampled residents (Resident 60) and two nonsampled residents (Residents 73 and 685).

* The facility failed to ensure Resident 73's omeprazole (acid reflux medication) medication bottle was shaken well prior to administering the medication as per the instruction on the bottle.

* The facility failed to ensure the narcotic medication for Residents 60 and 685 were accurately signed out and documented as per the facility's P&P.

These failures had the risk for negative health outcomes to the residents and the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber) and unsafe handling of the narcotic medications.

Findings:

Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be administered in accordance with the orders. The medications must be administered in accordance with State and Federal guidelines. The P&P further showed the licensed nurse must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration

before giving the medication.

Review of the facility's P&P titled Medication Administration - Controlled Substances revised 1/2023 showed

the controlled medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The P&P further showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the flowing information on the accountability record when removing dose from the controlled storage. Administer the controlled medication and document dose administration on the MAR.

According to the United States Drug Enforcement Administration (DEA), oxycodone (pain medication) is categorized as a Schedule II narcotic. Tramadol (pain medication) is categorized as a Schedule IV (low potential for abuse) narcotic. The DEA labels these drugs as having a potential for abuse.

1. Medical record review for Resident 73 was initiated on 4/22/25. Resident 73 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 73's H&P examination dated 11/4/24, showed the resident had a history of neurocognitive disorder (group of conditions that primarily affect cognitive abilities like memory, language, and problem solving) and was mostly non-verbal with global weakness (general lack of physical and/or mental strength and fatigue).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0755 Review of Resident 73's Order Summary Report for April 2025 showed a physician's order dated 1/2/25, to administer 10 ml of omeprazole oral suspension two mg/ml via GT one time a day for GERD. Level of Harm - Minimal harm or potential for actual harm Review of Resident 73's omeprazole medication bottle showed the instructions to shake well.

Residents Affected - Few On 4/22/25 at 0835 hours, during the medication administration observation, LVN 7 was observed pouring Resident 73's omeprazole into a medication cup. LVN 7 did not shake the bottle well as instructed prior to pouring the omeprazole medication into the medication cup.

On 4/22/25 at 0918 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings. LVN 7 verified the omeprazole medication bottle had instructions to shake

the bottle well prior to administering. LVN 7 stated the bottle should be shaken well to ensure the concentrate at the bottom of the bottle was distributed.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

2. a. Medical record review for Resident 60 was initiated on 4/22/25. Resident 60 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 60's H&P examination dated 4/15/25, showed the resident had the capacity to make decisions.

Review of Resident 60's Order Summary Report for April 2025 showed a physician's order dated 3/2/25, to administer tramadol (opioid medication) 50 mg one tablet by mouth three times a day for pain management; and to hold if the respiratory rate less than 12 breaths per minute. The tramadol medication was scheduled to be administered at 0930, 1530, and 2130 hours.

Review of Resident 60's MAR for April 2025 showed the tramadol 50 mg tablet was administered on 4/22/25 at 0930 hours.

Review of Resident 60's tramadol narcotic bubble pack showed there was one tablet of tramadol 50 mg medication remaining.

However, review of Resident 60's Controlled Drug Record initiated on 4/19/25, showed there should be two tramadol 50 mg tablets remaining instead of one tablet as showed in the bubble pack.

On 4/22/25 at 1129 hours, an inspection of the Controlled Drug Record at Medication Cart A was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 stated the narcotic bubble pack and the Controlled Drug Record sheet did not match. LVN 4 stated it should match to ensure the accuracy and to show the medication was administered.

On 4/22/25 at 1145 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified the above findings. LVN 10 stated the facility protocol was to sign the Controlled Drug

Record and the MAR when administering the narcotic medications, to ensure there were no errors in the narcotic count.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0755 b. Medical record review for Resident 685 was initiated on 4/22/25. Resident 685 was admitted to the facility

on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 685's H&P examination dated 4/17/25, showed the resident had no capacity to understand and make decisions. Residents Affected - Few

Review of Resident 685's Order Summary Report for April 2025 showed a physician's order dated 4/17/25, to administer oxycodone (opioid medication) 5 mg one tablet by mouth in the morning for pain management, hold for AMS or if the respiratory rate was less than 12 breaths per minute and to notify the physician.

Review of Resident 685's MAR for April 2025 showed the oxycodone 5 mg tablet was administered on 4/22/25 at 0900 hours.

Review of Resident 685's oxycodone narcotic bubble pack showed there were three tablets of oxycodone 5 mg remaining.

However, review of Resident 685's Controlled Drug Record initiated on 4/16/25, showed there should be four oxycodone 5 mg tablets remaining instead of three tablets as showed in the bubble pack.

On 4/22/25 at 1359 hours, an inspection of the Controlled Drug Record at Medication Cart B was conducted with LVN 16. LVN 16 verified the above findings. LVN 16 stated the narcotic bubble pack and Controlled Drug Record sheet should match.

On 4/28/25 at 1206 hours, and interview with the DON was conducted. The DON stated the facility's expectation was for the licensed nurses to sign the controlled drug sheet once the licensed nurses removed

the narcotic medication from the bubble pack and signed the MAR. The DON further stated the licensed nurses must sign out the medication on the controlled drug sheet and MAR to avoid diversion.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37726 potential for actual harm Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final Residents Affected - Few sampled residents (Resident 81) was free from the unnecessary medications.

* The facility failed to follow the physician's order to hold the amlodipine, metoprolol, and hydralazine (antihypertensive medications) medications when Residents 81's systolic blood pressure (the top number in

a blood pressure measurement) was less than 110 mmHg. This failure had the potential for Resident 81 to develop significant side effects.

Findings:

Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be administered in accordance with the orders.

Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE REDACTED].

Review of Resident 81's physician's order dated 11/3/24, showed to administer amlodipine 10 mg via GT once a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg.

Review of Resident 81's physician's order dated 11/3/24, showed to administer hydralazine 50 mg via GT three times a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg.

Review of Resident 81's physician's order dated 11/3/24, showed to administer metoprolol 50 mg via GT two times a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg.

Review of Resident 81's Medication Administration Records for 3/2025 and 4/2025 showed the amlodipine 10 mg, hydralazine 50 mg, and metoprolol 50 mg medications were administered by LVN 7, on the following dates/times when Resident 81's systolic blood pressure was less than 110 mmHg:

* On 3/14/25 at 0900 hours, the amlodipine 10 mg, metoprolol 50 mg, and hydralazine 50 mg medications were administered when Resident 81's systolic blood pressure was 108 mmHg.

* On 4/7/25 at 1300 hours, the hydralazine 50 mg medication was administered when Resident 81's systolic blood pressure was 106 mmHg.

* On 4/16/25 at 1300 hours, the hydralazine 50 mg medication was administered when Resident 81's systolic blood pressure was 105 mmHg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0757 On 4/24/25 at 1057 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified she administered the amlodipine 10 mg, metoprolol 50 mg, and hydralazine 50 mg Level of Harm - Minimal harm or medications on the above listed dates and times when Resident 81's systolic blood pressure was less than potential for actual harm 110 mmHg.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47474 Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide

the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following:

* The facility failed to ensure the oral and suppository medications in Medication Cart D were stored separately.

* The facility failed to ensure the opened and expired medications and medical supplies in Medication Cart E were properly disposed.

* The facility failed to ensure the expired medical supplies were removed from Medication Room B.

* The facility failed to ensure Resident 81 and 95's latanoprost 0.005% (glaucoma medication) eye drops were labeled with the opened date; and failed to discard Resident 95's latanoprost 0.005% eyedrop after the beyond-use by date in Medication Cart C.

* The facility failed to ensure the opened collagen powder and opened hydrofera blue (antibacterial foam) dressing were discarded after opening in Medication Cart F.

* The facility failed to ensure Resident 136's Norwegian fish oil was stored safely.

* The facility failed to ensure Resident 785's Refresh Relieva (lubricant eye drop) eye drop was not stored at

the bedside.

These failures had the potential to negatively impact the residents' well-being and the potential for the medications to lose the stability and effectiveness.

Findings:

Review of the facility's P&P titled Labeling of Biologicals and Storage of Biologicals revised 3/2022 showed

the facility will provide accurate labeling to facilitate precautions and safe administration of medications, and safe and secure storage. The P&P also showed drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary infections, and the expiration date when applicable.

1. On 4/22/25 at 1129 hours, an inspection of Medication Cart D and concurrent interview was conducted with LVN 4. LVN 4 verified the following medications were stored together:

- six acetaminophen 650 mg (pain medication) suppositories;

- three bisacodyl laxative 10 mg (stool softener medication) suppositories; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0761 - eight ondansetron ODT (orally dissolving tablet) 4 mg (nausea and vomiting medication) tablets

Level of Harm - Minimal harm or LVN 4 stated the oral and suppository medications should not be stored together. LVN 4 stated the potential for actual harm medications were organized based on the route for the medication to be administered to ensure the oral and suppository medications were not mixed up. Residents Affected - Few 2. On 4/22/25 at 1346 hours, an inspection of Medication Cart E and concurrent interview was conducted with RN 2. The following medical supplies and medications were observed:

- one 0.9 % sodium chloride (normal saline) syringe was opened ;

- one bandage roll was opened;

- two sterile gloves were opened; and

- two IV secondary administration sets had expired on 8/12/24.

RN 2 verified the findings and stated the expired items should be discarded to ensure the integrity of the medical supply. RN 2 also stated the 0.9% sodium chloride syringe, the bandage, and the sterile gloves should have been closed to ensure the medication and medical supplies were not used and kept sterile.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

48882

3. On 4/22/25 at 1132 hours, during the inspection of Medication Room B with LVN 7, the following was observed:

- two collection swabs with the expiration date of 11/30/22,

- one administration set with the expiration date of 1/7/25,

- two scabies collection kits with the expiration date of 1/13/25,

- one 23 g injection needle with three ml syringe with the expiration date of 3/31/25,

- one 4 ml vacutainer with the expiration date of 11/30/24,

- one 6 ml vacutainer with the expiration date of 1/31/25,

- one 8 ml vacutainer with the expiration date of 12/31/24, and

- one 8 ml vacutainer with the expiration date of 3/31/25.

LVN 7 verified the above findings and stated the expired supplies should be removed from the medication room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0761 4. Review of the facility document titled Ophthalmic Medication Beyond-Use Date Guide dated 4/2024 showed the expiration date for the latanoprost (glaucoma medication) solution 0.005% was 42 days after Level of Harm - Minimal harm or opening. potential for actual harm

On 4/22/25 at 1419 hours, during the inspection of Medication Cart C with LVN 8, the following medications Residents Affected - Few was observed:

- one opened bottle of latanoprost 0.005% eye drops for Resident 95, labeled 2/12/25 (69 days from the opened date).

- one opened bottle of latanoprost 0.005% eye drops for Resident 95 was not labeled with an opened date.

- one opened bottle of latanoprost 0.005% eye drops for Resident 81 was not labeled with an opened date.

LVN 8 verified the above findings. LVN 8 stated the eye drop medications should be labeled with the opened date when the medication was first opened to determine the discard date. LVN 8 further stated the eye drops should be discarded after 28 days after opening.

5. On 4/24/25 at 0753 hours, an inspection of Medication Cart F was conducted with LVN 11 and the following was observed:

- one opened packet of type 1 bovine collagen powder (wound filler dressing) labeled with the opened date of 4/18/25. The instructions on the packet showed to not use if the package was opened or damaged. Do not reuse. Sterile unless package was opened or damaged.

- one opened and cut hydrofera blue (antibacterial foam) dressing.

LVN 11 verified the above findings.

On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated all eye drop medications should be labeled with the opened date to determine the discard date. The DON stated the licensed nurses were responsible for checking the medication rooms weekly and expected to remove the expired supplies during the weekly inspection. The DON stated the licensed nurses assigned to the medication carts were responsible for the storage of medications inside the medication cart and should ensure the medications inside the medication carts were labeled properly with the opened date and removed from the medications carts when expired. The DON stated the collagen powder was for single use and should not be kept once opened. The DON added the hydrofera blue dressing should be sterile and it was for one-time use. The DON stated the unused portion of the collagen powder and hydrofera blue dressing should be discarded.

On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings

47476

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0761 6.a. On 4/21/25 at 0859 hours, a concurrent observation of Refrigerator B and interview was conducted with

the Activities Director in Dining Room B. A bottle of Norwegian fish oil supplement medication was observed Level of Harm - Minimal harm or in the refrigerator labeled with an open date of 11/2/24. There was no resident name or room number on the potential for actual harm bottle. The Activities Director verified the findings.

Residents Affected - Few Medical record review for Resident 136 was initiated on 4/21/25. Resident 136 was admitted to the facility on [DATE REDACTED].

Review of Resident 136's Order Summary Report dated 4/23/25, showed a physician's order dated 9/24/25, for 1/2 (half) teaspoon of Norwegian Omega 3s via GT in the morning for supplement, in fridge, and the family provided.

b. On 4/22/25 at 1112 hours, a concurrent observation of Refrigerator B and interview was conducted with

the Activities Assistant in Dining Room B. An unlabeled bottle of Norwegian fish oil supplement medication was observed in Refrigerator B. The Activities Assistant then asked LVN 10 about the fish oil and verified the Norwegian fish oil bottle medication was for Resident 136's.

On 4/22/25 at 1115 hours, a concurrent interview and medical record review was conducted with LVN 10. LVN 10 stated Resident 136's daughter brought in the Norwegian fish oil medication and the LVNs had been providing Resident 136 the fish oil every morning since November. LVN 10 verified the physician's order for

the Norwegian fish oil. LVN 10 verified the Norwegian fish oil was a medication and should be stored in the medication room.

On 4/24/25 at 1345 hours, an interview was conducted with the DON. The DON stated the fish oil was a medication, should be stored in the medication room, and should be labeled with the resident's name, date opened, and directions for use.

47746

7. On 4/21/25 at 0816 hours, during the initial tour of the facility, a bottle of Refresh Relieva eye drop was observed on the resident's cabinet.

On 4/21/25 at 0839 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above findings and stated Resident 785 was unable to administer the eye drop independently.

Medical record review for Resident 785 was initiated on 4/21/25. Resident 785 was admitted to the facility on [DATE REDACTED].

Review of Resident 785's H&P examination dated 4/17/25, showed the resident had no capacity to understand or make decisions.

Review of Resident 785's Order Summary Report dated 4/22/25, showed a physician's order dated 4/21/25, to administer one drop of Refresh Optive Advanced PF (lubricant eye drop) ophthalmic solution to both eyes every six hours as needed for dry eyes. However, further review of Resident 785's physician's orders failed to show the physician's orders for the use of the Refresh Relieva eye drop and/or to store the medication at

the bedside prior to 4/21/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0761 On 4/22/25 at 1419 hours, an interview and concurrent medical record review for Resident 785 was conducted with LVN 1. LVN 1 verified there was no physician's orders for the use of the Refresh Relieva eye Level of Harm - Minimal harm or drop and/or to store the medication at the bedside prior to 4/21/25. LVN 1 stated he notified Resident 785's potential for actual harm physician on 4/21/25, to obtain the physician's order for the Refresh Relieva eye drop, after he verified the resident was observed with the eye drop at the bedside. Residents Affected - Few

On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 47476

Residents Affected - Few Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 45 of 171 residents who received food from the kitchen received the proper diets when the facility's menu was not followed.

* The facility failed to ensure 45 residents who were on CCHO diets (diets for diabetics) and three residents who were on renal diets (specialized diet designed to support kidney health) received the homemade barbeque (BBQ) sauce with their oven BBQ beef roast as per the menu and recipe. This failure had the potential for the residents' nutritional needs not being met, which could result in medical complications.

Findings:

Review of the Diet Order Tally Report dated 4/21/25, showed 171 of 182 residents received food from the kitchen.

Review of the Diet Order Tally Report - All Special Diets dated 4/21/25, showed 45 residents were on CCHO diets and three residents were on renal diets.

Review of the facility's P&P titled Menus revised 9/2021 showed the facility provides meals to the residents that meet requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. Food served should adhere to the written menu.

Review of the facility's document titled Spring Cycle Menus, Week 4 Wednesday dated 4/23/25, showed the beef roast for the CCHO and renal diets was to be served with the homemade BBQ sauce.

Review of the facility document titled Recipe: Oven BBQ Beef Roast Week 4 Wednesday dated 2024 showed the following recipe for the special diets:

- For the renal diets, to make with low sodium BBQ sauce or homemade BBQ sauce; and

- For the CCHO diets, to make with homemade BBQ sauce.

Review of the facility document titled Recipe: Homemade BBQ sauce dated 2025 showed a recipe for BBQ sauce and to use as indicated with other recipes and spreadsheets.

On 4/23/25 at 1133 hours, during the lunch tray line observation, [NAME] 1 was observed to have served the prepared beef roast for all the therapeutic diets with the same BBQ sauce.

On 4/23/25 at 1254 hours, an observation and concurrent interview was conducted with the DSS and [NAME] 1. The DSS stated the facility used a bottled BBQ sauce for the beef roast. The DSS and [NAME] 1 verified the same bottled BBQ sauce was used for all of the therapeutic diets and there was no homemade BBQ sauce.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0803 On 4/8/25 at 1200 hours, an interview was conducted with RD 1. RD 1 was informed of the above findings. RD 1 stated the kitchen staff should be following the recipes. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476

Residents Affected - Some Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the sanitary requirements were met in the kitchen and resident food storage areas.

* The facility failed to ensure the resident carafes were air dried.

* The facility failed to ensure the food in the cold and dry storage areas were labeled, dated, and the expired items were thrown out.

* The facility failed to ensure the food preparation equipment was clean and free from damage.

* The facility failed to ensure the freezer in Refrigerator A, located in Dining Room A and Refrigerator B, located in Dining Room B were monitored for the temperatures and recorded in the temperature log.

* The facility failed to ensure the resident's food items in Refrigerators A and B were properly labeled and dated. Additionally, the resident's food items of Resident 13 and 735's personal refrigerators were not properly labeled and dated.

* The facility failed to ensure the temperature of the personal refrigerator for Resident 13 was at or below 41 degrees F.

* The facility failed to ensure the dishwasher's chlorine concentration met the minimum concentration of 50 ppm.

* The facility failed to ensure the quaternary sanitizer test paper was not expired.

* Resident 19 had expired deli sandwich meat in the resident's private refrigerator.

* Resident 986 had undated food items in the resident's private refrigerator.

These failures had the potential to expose the residents who received food from the kitchen to foodborne illnesses.

Findings:

Review of the Diet Order Tally Report dated [DATE REDACTED], showed 171 of 182 residents received food from the kitchen.

Review of the facility's P&P titled Use And Storage of Food Brought To Resident revised [DATE REDACTED] showed the food brought to the residents will be stored for no more than 48 hours, must be labeled with the resident's name, dated, and ensure it is used by the use by date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0812 1. According to the USDA Food Code 2022 Section ,d+[DATE REDACTED].11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried. Level of Harm - Minimal harm or potential for actual harm On [DATE REDACTED] at 0801 hours, during an initial tour of the kitchen with the DSS, resident plastic carafes were observed stored on top of a sheet pan on a clean storage rack. Four of the resident carafes were observed Residents Affected - Some with condensation on the inside. The DSS verified the finding and stated the kitchen staff would usually have

a netting underneath to air dry.

2. Review of the facility's P&P titled Labeling and Dating of Foods dated 2020 showed all the food items in

the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows the guidelines.

On [DATE REDACTED] at 0805 hours, during an initial tour of the kitchen and concurrent interview with the DSS, the following was observed:

- Six containers of diced peaches had the use by dates of ,d+[DATE REDACTED] and ,d+[DATE REDACTED] in Refrigerator C. The DSS verified the items had expired and removed them from the refrigerator.

- A bin of thickener was undated in the dry storage area.

- A bin of brown rice was undated in the dry storage area.

- 10 heads of lettuce were wilted with brown areas in the Refrigerator D.

- One bottle of cranberry juice cocktail was without a use by date in Refrigerator D.

- One bottle of chocolate flavored syrup was without a use by date in Refrigerator D.

- One opened bag of wafer cookies was undated in the dry storage room.

- One bag of cherry gelatin mix was without a use by date in the dry storage room.

- One bag of potato chips was without a use by date in the dry storage room.

The DSS verified the findings.

3. According to the USDA Food Code 2022 Section ,d+[DATE REDACTED].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Review of the facility's P&P titled Sanitation dated 2018 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, crack and chipped areas.

a. On [DATE REDACTED] at 0823 hours, during an initial tour of the kitchen and concurrent interview with the DSS, the following was observed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0812 - The can opener blade was observed with brown and yellow residue.

Level of Harm - Minimal harm or - The kitchen microwave was observed with yellow stains on the top wall and yellow residues on the bottom potential for actual harm wall.

Residents Affected - Some The DSS verified the above findings.

b. On [DATE REDACTED] at 0905 hours, an observation and concurrent interview was conducted with LVN 11 in the Station A utility room. The resident's microwave was observed to have an orange and black stain on the inside corner back wall, with chipped areas. LVN 11 stated the housekeeping staff would clean the microwave.

On [DATE REDACTED] at 1119 hours, an observation and concurrent interview was conducted with the Maintenance Director in the Station A utility room. The resident's microwave was observed to have an orange and black stain on the inside corner back wall, with chipped areas. The Maintenance Director started to scrape the back wall of the microwave and stated it was a liquid burn that damaged the coating. The Maintenance Director stated he would take the microwave out and bring another one.

4. Review of the facility's P&P titled Refrigerator/Freezer Temperature Records revised ,d+[DATE REDACTED] showed a daily temperature record is to be kept for refrigerated and frozen storage areas. The freezer temperature must be zero degrees F or below.

a. On [DATE REDACTED] at 0838 hours, an observation and concurrent interview was conducted with LVN 15 in Dining Room A for Refrigerator A. LVN 15 was asked about the temperature log for the freezer. LVN 15 verified there were food items in the freezer, however, there was no freezer temperature log.

b. On [DATE REDACTED] at 0859 hours, an observation and concurrent interview was conducted with the Activities Director in Dining Room B for Refrigerator B. The Activities Director verified there were food items in the freezer; however, there was no freezer temperature log.

On [DATE REDACTED] at 0916 hours, an observation and concurrent interview was conducted with Housekeeping 1, translated by CNA 7, in Dining Room B. Housekeeping 1 stated she would clean Refrigerator B and would check the temperatures everyday. Housekeeping 1 stated she checked the freezer temperature; however,

she would only document the refrigerator temperature. Housekeeping 1 verified the facility did not have a freezer temperature log.

On [DATE REDACTED] at 0937 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the findings. The Maintenance Director stated the facility staff did not check the freezer temperatures for the refrigerators in Dining Rooms A and B .

5. Review of the facility's P&P titled Use and Storage of Food Brought to Resident revised ,d+[DATE REDACTED] showed to ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to resident's by family and visitors for a period not to exceed 48 hours. Perishable foods must be stored in the refrigerator .containers will be labeled with the resident's name, and

the manufacturer use-by date as applicable. Labeling, dating, and monitoring refrigerated food, including leftovers, so it is used by its use-by date or frozen or discarded in accordance with acceptable standards of safe food storage guidelines, shall be the responsibility of the designated facility staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0812 a. On [DATE REDACTED] at 0838 hours, an observation and concurrent interview was conducted with LVN 15 in Dining Room A for Refrigerator A. On the side of the refrigerator was a sign posted showing All items in the Level of Harm - Minimal harm or refrigerator must be labeled and dated; Label must say resident's name, room number, and dated; Any foods potential for actual harm without label or dates will be discarded; Any food stored longer than three days will be discarded. LVN 15 stated the activities staff was responsible to check for the expired food. The following was observed: Residents Affected - Some - Two bags of bread without a name or date;

- One [NAME] drink with a straw inside it, unlabeled;

- One round cake in a container, unlabeled; and

- One food container with liquid for Resident A dated ,d+[DATE REDACTED].

LVN 15 verified the above findings

On [DATE REDACTED] at 0855 hours, an observation and concurrent interview was conducted with the Activities Director

in Dining Room A for Refrigerator A. The Activities Director stated their responsibility for the resident's refrigerators were to check the temperature logs and together with the housekeeping staff, would check the food for a label and if the food items were older than three days. The Activities Director stated she would label the food with the room number, name, and date the food came in. The Activities Director stated Resident A's food should have been thrown out the day prior.

b. On [DATE REDACTED] at 0859 hours, an observation and concurrent interview was conducted with the Activities Director in Dining Room B for Refrigerator B. The following was observed and verified with the Activities Director:

- One opened and one unopened Breyers chocolate ice cream, unlabeled;

- One opened bottle of cranberry juice dated [DATE REDACTED];

- One yogurt with a best by date of [DATE REDACTED];

- One opened bottle of apple sauce dated [DATE REDACTED];

- One bag with illegible writing containing prepared food items;

- One opened black forest ham package for Resident 40 dated [DATE REDACTED]; and

- One opened cheese tray for Resident 40 dated [DATE REDACTED].

The Activities Director stated she needed to re-inservice the facility staff to talk to the residents' family members about labeling of the food items.

c. On [DATE REDACTED] at 1054 hours, an observation and concurrent interview was conducted with Resident 13 in his room. Resident 13's personal refrigerator was observed with food items, including bottled sauces, cartons of milk, and packaged cheeses, which were unlabeled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0812 On [DATE REDACTED] at 1604 hours, an observation and concurrent interview was conducted with RN 3 in Resident 13's room. RN 3 opened Resident 13's personal refrigerator and verified Resident 13's food items were not Level of Harm - Minimal harm or labeled. potential for actual harm d. On [DATE REDACTED] at 1522 hours, an observation and concurrent interview was conducted with Resident 735 in Residents Affected - Some her room. Resident 735's personal refrigerator was observed with five covered food containers from the kitchen, unlabeled. Resident 735 stated she refrigerated her soups from the kitchen.

On [DATE REDACTED] at 1609 hours, an observation and concurrent interview was conducted with RN 3 in Resident 735's room. RN 3 opened Resident 13's personal refrigerator and verified the food items were unlabeled.

6. Review of the facility's P&P titled Refrigerator/Freezer Temperature Records revised ,d+[DATE REDACTED] showed

the refrigerator temperature must be 41 degrees F or below.

On [DATE REDACTED] at 1054 hours, an observation and concurrent interview was conducted with Resident 13 in his room. Resident 13's personal refrigerator's thermometer was observed to read 52 degrees F. Resident 13 stated he might need a new thermometer. The refrigerator was observed with food items, including sauces, covered items from the kitchen, cartons of milk, and packaged cheeses.

On [DATE REDACTED] at 1604 hours, an observation and concurrent interview was conducted with RN 3 in Resident 13's room. RN 3 opened Resident 13's personal refrigerator and verified the thermometer read 48 degrees F. RN 3 stated she did not know what the refrigerator temperature should be.

On [DATE REDACTED] at 1615 hours, an interview was conducted with LVN 2 and RN 3. LVN 2 stated the resident refrigerator needed to be less than 40 degrees F. LVN 2 stated he would need to throw out the items in the refrigerators with the out-of range temperature.

On [DATE REDACTED] at 1119 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated the housekeeping staff checked the temperatures of the personal refrigerators daily. The Maintenance Director stated if the temperatures were out of range, he would replace

the thermometer or would need to fix the refrigerator. The Maintenance Director was informed of the above findings. The Maintenance Director then went to Resident 13's room, opened the personal refrigerator, and checked the temperature. The temperature was observed to be 50 degrees F. The Maintenance Director stated he would need to get a new thermometer and Resident 13 left the refrigerator door open frequently.

7. Review of the facility's P&P titled Dishwashing dated 2018 showed for a low temperature machine, the chlorine should read ,d+[DATE REDACTED] ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing dishes. If you do not achieve the proper temperature or chlorine level, resort to the manual method of dishwashing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0812 On [DATE REDACTED] at 0909 hours, an observation of the facility's dishwashing machine was conducted with Dietary Aide 1 with translation by the Dietary Assistant Supervisor. Dietary Aide 3 was observed clearing dishes on Level of Harm - Minimal harm or the dirty side, Dietary Aide 1 was observed placing the dishes in the dishwasher, and Dietary Aide 2 was potential for actual harm observed on the clean side, putting the dishes away. Several cycles of dishwashing were observed, and Dietary Aide 2 was observed to put dish domes, trays, and plates away. Dietary Aide 1 was asked how he Residents Affected - Some checked if the machine was working and demonstrated how he checked the sanitizer solution. Dietary Aide 1 stated the solution should test at ,d+[DATE REDACTED] ppm. The test strip was observed to have a lighter color than 50 ppm (the sanitizer solution concentration did not reach 50 ppm). The Dietary Assistant Supervisor then tested the sanitizer solution and verified the sanitizer solution concentration was lower than 50 ppm. The DSS stated she would call the Dishwasher Company. The Dietary Assistant Supervisor stated the kitchen staff would stop the dishwashing and wait for the Dishwasher Company to come.

On [DATE REDACTED] at 0956 hours, a follow-up interview was conducted with the DSS. The DSS stated for the dishes which were already washed, they would have to re-run the dishes through the dishwasher once the Dishwasher Company Employee came.

On [DATE REDACTED] at 1106 hours, the Dishwasher Company Employee was observed finishing the repair of the facility's dishwashing machine. The Dishwasher Company Employee verified the dishwashing machine was fixed and stated he needed to change the chlorine sanitizer solution line.

8. On [DATE REDACTED] at 1518 hours, an observation and concurrent interview was conducted with Dietary Aide 4 and

the DSS regarding the changing out and testing for the quaternary ammonium sanitizer solution used for their red buckets. The Quat-10 test paper used to test the sanitizer solution showed an expiration date of [DATE REDACTED]. The DSS verified the Quat-10 test paper was expired and brought new Quat-10 test paper to Dietary Aide 4. The DSS stated using the expired test strips, the reading could be wrong.

39683

9. On [DATE REDACTED] at 0908 hours, an observation of Resident 19's private refrigerator and concurrent interview was conducted with CNA 3. There was an unopened package of turkey breast deli meat with a use by date of [DATE REDACTED], stored inside the refrigerator. CNA 3 verified the turkey breast was kept past the used by date.

10. On [DATE REDACTED] at 0928 hours, an observation of Resident 986's private refrigerator and concurrent interview was conducted with LVN 2. There was an undated and unlabeled resealable bag of noodles stored inside the refrigerator. LVN 2 verified the bag of noodles was not dated and labeled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 47476 potential for actual harm Based on interview and facility P&P review, the facility failed to ensure the facility staff responsible for Residents Affected - Few handling food brought for the residents from the outside and family/visitors who brought food for the residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources.

Findings:

Review of the facility's P&P titled Use and Storage of Food Brought to Resident revised 3/2023 showed the facility has procedures to ensure safe and sanitary storage, handling, and consumption of the foods brought to the residents by the family and other visitors. The facility strives to support each resident's right to safe food storage, handling, and preparation. To ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to the residents by the family and visitors for a period not to exceed 48 hours, and in accordance with the following guidelines. The facility helps the family and visitors to understand safe food handling practices.

On 4/21/25 at 1230 hours, an observation and concurrent interview was conducted with Resident 88 in her room. Resident 88's personal refrigerator was observed to contain several foil-covered plates.

On 4/23/25 at 0910 hours, an observation and concurrent interview was conducted with CNA 5. CNA 5 stated the facility stored the residents' food in the dining room refrigerator. CNA 5 stated she reheated the food in the residents' microwave. When asked how she reheated the food, CNA 5 stated the resident would tell her how long they wanted the food to be microwaved. CNA 5 stated the facility had a thermometer in the utility room to check the temperatures of the reheated food; however, when the utility room microwave was checked with CNA 5, there was no thermometer observed.

On 4/23/25 at 0912 hours, an interview was conducted with LVN 12. LVN 12 stated the safe food handling included to make sure the food did not burn the resident when the food was very hot. When asked what she educated the family members regarding the safe food handling, LVN 12 stated the food had to be thrown out within a three-day period, so the resident would not get sick from eating the old food. LVN 12 was unable to recall if she received any in-service education regarding the safe food handling.

On 4/23/25 at 0926 hours, an interview was conducted with CNA 6. CNA 6 stated the safe food handling included hand washing and labeling the food with a name and date. CNA 6 stated if a family member brought

in food for a resident, he would not tell the family member anything and would let the resident eat the food.

On 4/23/25 at 0929 hours, an interview was conducted with LVN 13. LVN 13 stated if she reheated food for a resident, she would ask how hot they wanted the food, re-heated the food, then checked with the resident if

the food was warm enough. LVN 13 stated she was not sure if she had been educated regarding the safe food handling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0813 On 4/23/25 at 0934 hours, an interview was conducted with LVN 14. LVN 14 verified there were residents who had family members bring in food from the outside. LVN 14 stated the facility would check the food to Level of Harm - Minimal harm or make sure it was aligned with the resident's diet and would inform the next shift about the food. LVN 14 potential for actual harm stated the facility staff would inform the family member that the facility would be storing the food for two days. LVN 14 stated she had not been educated regarding the safe food handling. Residents Affected - Few

On 4/23/25 at 0942 hours, an interview was conducted with the Admissions Designee. The Admissions Designee stated on the admission, the admissions staff would educate the family members to make sure

they talked with the nursing staff about the food from the outside and if it aligned with the resident's diet. The Admissions Designee stated the admissiona staff provided the facility's policy titled Use and Storage of Food Brought to Resident in the facility's admission packet and verified the admissions staff did not provide information specific to the safe food handling.

On 4/23/25 at 1000 hours, an interview was conducted with the DSD. The DSD stated the safe food handling included having the CNAs sanitize their hands and for the licensed nurses to check on the meals before it was sent out to the resident. The DSD stated when she provided the in-services to the facility staff, she would instruct the facility staff to label and date the food item and to endorse to the next shift if the resident wanted to eat it at the following mealtime. When asked if she provided education specific to the safe food handling to the facility staff, the DSD stated she had not educated the facility staff about the safe food handling.

On 4/23/25 at 1013 hours, an interview was conducted with RD 1. RD 1 stated she had not provided education to the nursing staff regarding the safe food handling. RD 1 stated she did not educate everyone who brought in food and could not guarantee they had the safe food handling practices.

On 4/23/25 at 1435 hours, an interview was conducted with Family Member 1. Family Member 1 stated she had brought Resident 88 a traditional lamb dish for Easter Sunday. Family Member 1 stated she had not been educated by the facility regarding the safe food handling and stated the facility did not instruct her regarding bringing in food from the outside.

On 4/28/25 at 1450 hours, an interview was conducted with the Administrator, DON, ADON, Nurse Consultant, RD 1, and DSS. The Administrator, DON, ADON, Nurse Consultant, RD 1, and DSS acknowledged the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Potential for 39683 minimal harm Based on observation, interview, and facility P&P review, the facility failed to properly dispose of the Residents Affected - Some discarded cardboard boxes. This failure had the potential to attract rodents and pests that carried a disease.

Findings:

Review of the facility's P&P titled Dispose of Garbage And Refuse revised March 2023 showed the facility will properly dispose of the garbage and refuse, waste will be contained in dumpsters or bins with lids to prevent harboring of pests.

On 4/25/25 at 0940 hours, an observation and concurrent interview was conducted with the Maintenance Director. A pile of broken-down and flattened cardboard boxes and a stack of carboard boxes were observed

on the ground against the building. The Maintenance Director stated the discarded boxes were stored there to be picked up weekly. The Maintenance Director verified the discarded boxes were not placed in a container with a lid.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37726

Residents Affected - Few Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for four of 35 final sampled residents (Residents 56, 80, 81, and 163) and one nonsampled resident (Resident 40).

* Resident 81 had conflicting orders for holding Resident 81's enteral feeding via GT, specific to the residuals.

* The facility failed to ensure the accurate and complete medical record for Resident 56.

* The facility failed to ensure the medication routes for Resident 163 with GT were accurate.

* The facility failed to ensure the documentation on the IV MAR was completed for Resident 80.

* Resident 40's consult psychiatrist's progress note was not part of the resident's medical record.

These failures had the potential for not providing necessary care and services due to inaccurate medical records.

Findings:

1. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE REDACTED].

Review of Resident 81's physician's order dated 11/3/24, showed to provide Glucerna (enteral feed type) 1.5 by enteral feeding pump (via GT) at a rate of 60 ml/hr for 20 hours.

Review of Resident 81's physician's order dated 11/3/24, showed to check and record the enteral feeding (gastric) residuals every shift and to hold the feeding one hour for residual greater than 100 ml.

Review of Resident 81's physician's order dated 11/8/24, showed to check the GT feeding (gastric) residuals every six hours and to hold the feeding for two hours if the residual greater or equal to 500 ml.

On 4/24/25 at 1235 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified Resident 81 had conflicting orders for holding Resident 81's enteral feeding, specific to gastric residuals. The DON stated the order needed to be clarified with Resident 81's physician to ensure the enteral feeding was administered in accordance with the appropriate gastric residual hold parameters.

44175

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0842 2. Medical record review for Resident 56 was initiated on 4/22/25. Resident 56 was admitted to the facility on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of the Resident 56's Physician Order Summary Report showed a physician order dated 2/26/24, for hydralazine (medication to lower the blood pressure), to monitor the blood pressure every eight hours and to Residents Affected - Few give hydralazine as needed if the systolic blood pressure more than 150 mmHg.

Review of Resident 56's MAR from 4/1/25 to 4/22/25, showed on 4/6, 4/7, 4/8, 4/9, and 4/18/25 at 1400 hours, failed to show documented evidence Resident 56's blood pressure was monitored. Further review of

the MAR showed the resident's blood pressure readings of 128/74 mmHg on 4/22/25 at 0600 and 1400 hours.

Review of Resident 56's medical record did not show documented evidence to explain why the resident's blood pressure was not monitored on 4/6, 4/7, 4/8, 4/9, and 4/18/25, as ordered by the physician.

On 4/22/25 at 1444 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings and stated she was not able to find documentation showing why the blood pressure was not monitored for Resident 56 on the above dates and time. LVN 7 stated on 4/22/25 at 1400 hours, Resident 56 refused the blood pressure monitoring; however, LVN 7 verified she documented the blood pressure for Resident 56 as 128/74 mmHg. LVN 7 stated she made a mistake and copied the blood pressure from the previous shift. LVN 7 stated she did not accurately document the blood pressure reading for Resident 56. LVN 7 further stated she should have documented accurately when Resident 56 refused the blood pressure monitoring.

On 4/25/25 at 0908 hours, an interview and concurrent medical record review for Residents 56 was conducted with the DON. The DON verified and acknowledged the above findings.

47474

3. Medical record review for Resident 163 was initiated on 4/21/25. Resident 163 was admitted to the facility

on [DATE REDACTED].

Review of Resident 163's H&P examination dated 3/24/25, showed the resident had no capacity to understand and make decisions.

Review of Resident 163's Admission Record showed Resident 163 had a GT.

Review of Resident 163's Order Summary Report for April 2025 showed the following physician's orders:

- dated 3/21/25, for NPO diet, NPO texture, NPO consistency;

- dated 3/21/25, to administer senna 8.6 mg (stool softener) one tablet by mouth every 12 hours as needed;

- dated 3/25/25, to administer vitamin D3 125 mcg (supplement) one tablet by mouth one time a day;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0842 - dated 4/13/25, to administer ferrous sulfate 325 mg (supplement) one tablet by mouth two times a day;

Level of Harm - Minimal harm or - dated 4/13/25, to administer vitamin C 500 mg (supplement) by mouth in the morning; potential for actual harm - dated 4/16/25, for aspiration precaution every shift; Residents Affected - Few - dated 4/19/25, to administer Decadron 2 mg (inflammation medication) by mouth two times a day for one day, then give one mg by mouth two times a day for two days, then give one mg by mouth one time a day for two days then give 0.5 mg by mouth one time a day for two days for anemia (condition where the blood does not carry enough oxygen to the body's tissues).

On 4/24/25 at 0925 hours, an interview and concurrent medical record review was conducted with LVN 16. LVN 16 verified the above findings. LVN 16 stated Resident 163 did not receive the medications or food by mouth and was NPO. LVN 16 further stated Resident 163's medication orders were not accurate and the route of medication administration should be via GT.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

47746

4. Review of the facility's P&P titled Medical Record Content revised 5/2019 showed the purpose of the policy is to ensure adequate and accurate documentation of care provided to each resident while at the facility. The Procedure section showed the medical record will be accurate, timely, and complete and may include the MAR and TAR.

Medical record review for Resident 80 was initiated on 4/21/25. Resident 80 was admitted to the facility on [DATE REDACTED].

Review of Resident 80's IV MAR for March 2025 showed the following entries had missing documentation from the licensed nurses on 3/14/25, for the day shift:

- for IV line order #2 (blood return check, then flush with 10 ml of normal saline before and after medication administration every shift);

- for IV line order #3 (flush to remain accessed and blood return check, then flushed with five ml of normal saline followed by 3 ml of Heparin (anticoagulant) 10 unit per ml before and after medication administration every shift); and

- for IV line order #5 (to monitor IV line and observe for reactions during infusion. Observe for signs and symptoms of infiltration or phlebitis (inflammation of the vein) before and after medication administration.

Further review of Resident 80's IV MAR for March 2025 showed the following entries had missing documentation from the licensed nurses:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0842 - dated 3/25/25, to administer daptomycin (antibiotic) 750 mg intravenously every 24 hours (at 1600 hours) for left foot osteomyelitis (bone infection) for four weeks; and Level of Harm - Minimal harm or potential for actual harm - dated 3/30 and 3/31/25, to administer ertapenem (antibiotic) 1 gram intravenously every 24 hours (at 2200 hours) for left foot osteomyelitis for four weeks. Residents Affected - Few

On 4/23/25 at 0958 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the IV MAR should be signed by the licensed nurses after administering the medications and completing the physician's orders.

On 4/23/25 at 1108 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified the above findings.

On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings.

39683

5. Review of the facility's P&P titled Medical Record Content revised 5/2019 showed the facility will maintain

an accurate medical record to facilitate continuity of care among health care providers by ensuring adequate and accurate documentation of care provided. The medical record will be accurate, timely and complete and may include consultant reports and physician progress notes.

Medical record review for Resident 40 was initiated on 4/17/25. Resident 40 was readmitted to the facility on [DATE REDACTED].

Review of Resident 40's Order Summary Report showed a physician's order dated 5/8/22, for a psychiatry evaluation and follow-up as needed.

Review of Resident 40's Care Plan Report showed on 9/26/24, the resident was seen by a psychiatrist.

Further review of the Resident 40's medical record failed to show the consultant psychiatrist's consult note.

On 4/28/25 at 1318 hours, an interview and concurrent record review was conducted with the DON. The DON stated she was unable to locate the consultant psychiatrist's progress note in the resident's records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47474 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Few the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for two of 35 final sampled residents (Residents 143 and 985) and one nonsampled resident (Resident 37) as evidence by the following:

* The facility failed to ensure the EBP was maintained for Resident 143 with a PICC line during an IV medication administration observation.

* The facility failed to ensure the visitors wore PPE in a contact isolation room for Resident 985.

* During the medication administration observation for Resident 37, LVN 6 failed to perform hand hygiene in between glove use.

* The clean laundry room had the facility staff's personal belongings and a Sani-cloth disinfectant wipe container with the clean linen.

* Resident 985's did not have a trash bin with a lid in their room, when the resident had a MDRO.

These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility.

Findings:

Review of the facility's P&P titled Enhanced Barrier Precautions revised 4/2024 showed Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of multidrug-resistant organism (MDRO) colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and wounds or presence of unhealed pressure ulcers. The P&P further showed indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities such as device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

According to the CDC's Transmission-Based Precaution - Infection Control Basics dated 4/2024 showed contact precautions are used for residents with known or suspected infections that represent an increased risk for contact transmission. Furthermore, use of PPE includes gloves and gown for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens.

1. Medical record review for Resident 143 was initiated on 4/21/25. Resident 143 was admitted to the facility

on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0880 Review of Resident 143's Order Summary Report for April 2025 showed the following physician orders:

Level of Harm - Minimal harm or - dated 3/13/25, to administer daptomycin (antibiotic medication) 450 mg intravenously once a day for sepsis potential for actual harm for six weeks.

Residents Affected - Few - dated 2/11/25, to change the central line cap every seven days and as needed or after blood draws.

Further review of Resident 143's Order Summary Report for April 2025 showed no documented evidence of

a physician's order for the EBP.

On 4/23/25 at 0905 hours, during the IV medication administration observation, RN 1 was observed administering the IV medication for Resident 143 via a PICC line to the resident's right upper arm. RN 1 was observed administering the IV medication with gloves on but without a gown. Furthermore, an observation outside of Resident 143's room showed no evidence an EBP signage was posted outside the resident's room.

On 4/23/25 at 0918 hours, an interview was conducted with RN 1. RN 1 verified the above findings. RN 1 also verified Resident 143 had a PICC to the right upper arm. RN 1 stated the residents with the PICC lines, GT, indwelling urinary catheters, wounds or colostomy were placed on EBP. RN 1 stated for EBP, the PPE included donning of the gown and gloves. RN 1 further stated there should be a physician's order for the EBP and an EBP signage should be posted outside of the resident's room.

2. Medical record review for Resident 985 was initiated on 4/21/25. Resident 985 was admitted to the facility

on [DATE REDACTED].

Review of Resident 985's H&P examination dated 4/19/25, showed the resident had the capacity to understand and make decisions.

Review of Resident 985's Order Summary Report for April 2025 showed the following physician orders:

- dated 4/21/25, for contact isolation related to the diagnosis of MDRO Serratia (type of bacterial infection) in

the urine every shift until 4/26/25.

- dated 4/18/25, for suprapubic indwelling urinary catheter size 16 FR/10 ml to drainage bag due to the diagnosis of urethral stricture.

Review of Resident 985's Care Plan Report dated 4/24/25, showed a care plan problem addressing the resident's isolation contact precautions related to UTI Serratia in the urine. The interventions included to maintain a contact precautions as indicated and to provide instructions and/or education to the resident, family, visitor, and facility staff regarding the contact precaution, proper use of the PPE when in direct contact with the resident and the materials needed and used by the resident.

On 4/24/25 at 0958 hours, Family Member 3 was observed sitting at the bedside without wearing PPE (gloves and gown). Family Member 3 verified he did not wear the PPE upon entering the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0880 On 4/24/25 at 1019 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 985 was on contact isolation and the visitors should wear Level of Harm - Minimal harm or their PPE while in the room for infection control and to protect the transmission of the infection. LVN 2 further potential for actual harm stated the contact isolation PPE included wearing the gown and gloves.

Residents Affected - Few On 4/28/25 at 0925 hours, an interview and concurrent medical record review was conducted with the DON.

The DON stated the PPE, including gloves and gown and mask as needed, was worn in a contact isolation room to prevent the spread of germs through direct or indirect contact with the resident or their environment.

The DON further stated the PPE was required for the facility staff and visitors.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

48882

3. Review of the facility's P&P titled Personal Protective Equipment revised 9/2023 showed hands are washed before and after removing of gloves.

Medical record review for Resident 37 was initiated on 4/22/25. Resident 37 was admitted to the facility on [DATE REDACTED].

Review of Resident 37's Order Summary Report for April 2025 showed a physician's order dated 4/25/24, to implement enhanced barrier precautions due to the indwelling urinary catheter medical device usage, every shift.

On 4/22/25 at 0901 hours, a medication administration observation was conducted with LVN 6 for Resident 37.

LVN 6 was observed preparing the following medications:

- one tablet of metformin (diabetic medication) 1000 mg,

- one tablet of enteric-coated aspirin (antiplatelet medication) 81 mg,

- one tablet of Januvia (diabetic medication) 100 mg,

- one tablet of multivitamin with mineral (supplement)

- 30 ml of LiquaCell-protein, and

- one bottle of olopatadine 0.7% (to treat allergic conjunctivitis) eyedrop.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0880 LVN 6 was observed donning gloves and entered Resident 37's room to administer the medications. After administering Resident 37's oral medications, LVN 6 was observed removing her gloves and donned a new Level of Harm - Minimal harm or pair of gloves. LVN 6 was not observed performing hand hygiene. LVN 6 then made contact with Resident potential for actual harm 37 and administered a drop of the olopatadine 0.7% eye drop into Resident 37's right eye. LVN 6 then removed her gloves and donned a new pair of gloves. LVN 6 was not observed performing hand hygiene. Residents Affected - Few LVN 6 then administered a drop of the olopatadine 0.7% eye drop medication into Resident 37's left eye.

On 4/22/25 at 0917 hours, a concurrent observation and interview was conducted with LVN 6. LVN 6 verified

the sign posted on Resident 37's room door showed to adhere to EBP for the residents in Beds A and C (Resident 37 was in bed C). LVN 6 stated Resident 37 was on enhanced barrier precautions for her indwelling urinary catheter. LVN 6 was asked about the process for the administration of the eye drops. LVN 6 stated when administering the eye drop medication for both eyes, separate gloves should be worn to prevent cross contamination. LVN 6 stated after removing the gloves, hand hygiene should be performed prior to donning a new pair of gloves. LVN 6 verified she did not perform hand hygiene between the glove use during the medication administration observation.

On 4/23/25 at 1103 hours, an interview was conducted with the IP. The IP stated the facility staff should don gown and gloves when anticipating coming in close contact with a resident who was on EBP. The IP stated

during the medication administration process, when a licensed nurse transitioned from administering oral medications to administering eye drops, the licensed nurse should doff the gloves, wash hands or perform hand hygiene, and then don a new pair of gloves. The IP further stated when administering eye drops for both eyes, the licensed nurse should doff gloves, perform hand hygiene and don a new pair of gloves, after administering the eye drop to one eye to prevent cross contamination.

On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings.

39683

4. On 4/25/25 at 0954 hours, an inspection of the facility's clean laundry room was conducted with the Maintenance Director and the Laundry Aide. The following were observed in the clean linen area:

- Staff's personal jacket and backpack were hanging on a hook next to the dryer, hanging over a bin of clean linen.

- Staff's personal cell phone and a plastic water bottle were sitting on the clean linen folding table, in contact with the clean linen.

- Staff's personal keys and keyring were on the table next to a pile of clean resident clothing.

- A container of Sani-clean disinfectant wipes was on the table touching a pile of clean resident clothing.

- Staff's plastic water bottle was on a pile of clean resident blankets in a clean laundry bin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0880 The Maintenance Director and Laundry Aide verified the above findings and stated the personal belongings and disinfectant wipes should not be near the clean linen areas. Level of Harm - Minimal harm or potential for actual harm 5. Medical record review for Resident 985 was initiated on 4/21/25. Resident 985 was admitted to the facility

on [DATE REDACTED]. Residents Affected - Few

Review of Resident 985's Order Summary Report showed a physician's order dated 4/21/25, for contact isolation for MDRO in the urine.

On 4/21/25 at 1205 hours, an observation of Resident 985's room and interview was conducted with LVN 2. LVN 2 verified the resident was in contact isolation for the MDRO, and the trash receptacle in the resident's room did not have a lid, and it should.

On 4/23/25 at 1441 hours, an interview was conducted with the IP. The IP stated for the residents on an isolation precautions for an active MDRO, they should have a trash bin with a lid. The IP verified Resident 985 had an active MDRO and should have a trash bin with a lid in their room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 48882 potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure the facility Residents Affected - Few equipment was maintained in the safe operating condition.

* For Medication Cart C, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. In addition, the facility failed to ensure the corrective actions were taken when the quality control results for the glucometer were out of range.

* The facility failed to ensure the serial number on the glucometer and on the Quality Control Record matched for Medication Cart B.

* The facility failed to ensure the quality control checks were performed for the glucometers in Medication Cart A and B.

These failures had the potential risk of inaccuracy for the residents' blood glucose test results.

Findings:

Review of the Assure Platinum (blood glucose monitoring system), User Instruction Manual (undated) showed to perform control solution tests in accordance with the state regulatory guidelines. To use the Assure Dose Control Solutions to check if: the meter and test strips are working correctly as a system, and you are testing correctly. There are two levels of control solution: Normal and High. Under the section for Performing a Control Solution Test showed to compare the result to the range printed on the test strip bottle. To make sure the result is within the acceptable range. If the result falls within this range, the meter and test strip are working correctly. Do not use the system if the control solution result is out of range. For professionals: to record the result in the quality logbook. Do not use the system to test the blood glucose until

the control solution result is within the range.

1. On 4/22/25 at 1419 hours, an inspection of Medication Cart C, interview, and concurrent facility document

review was conducted with LVN 8. Inspection of the medication cart showed the glucometer currently in use with the serial number of 1040-4428884.

However, review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for April 2025 for the glucometer for Medication Cart C showed the serial number of the glucometer was 1040-4209664 which did not match the serial number of the glucometer observed in Medication Cart C.

Further review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for April 2025 for Medication Cart C showed the following recorded control results:

- dated 4/2/25, the high control range was recorded as 209-261 mg/dL. The high control result showed 348 mg/dL, and the corrective action was recorded as 0; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 - dated 4/17/25, the high control range was recorded as 212- 264 mg/dL. The high control result showed 359 mg/dL, and the corrective action was recorded as 0. Level of Harm - Minimal harm or potential for actual harm LVN 8 verified the above findings. LVN 8 stated if the quality control result was out of range, a corrective action should have been completed. Residents Affected - Few

On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated the purpose of quality control test for the glucometer was to ensure the glucometer was working effectively to provide accurate results when checking the residents' blood sugar. The DON stated the quality control for the glucometers were conducted daily, during the night shift. The DON stated the serial number on the glucometer device should match the serial number documented on the quality control log. The DON stated if the control reading result was out of range, the licensed nurse should recheck and perform the quality control test again. The DON stated if the result was still out of range, another glucometer should be used. The DON further stated if

the result was out of range, she expected a corrective action to be documented.

On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings.

47474

2. Review of the facility document titled Assure Platinum Blood Glucose Monitoring System: Quality Control

Record for April 2025 for Medication Cart B, showed the serial number was 1040-4306369.

However, an inspection of the glucometer in use for Medication Cart B showed the serial number was 1040-4436257.

On 4/22/25 at 1421 hours, an inspection of the glucometer in Medication Cart B was conducted with LVN 4. LVN 4 verified the serial numbers for the glucometer in use and the quality control record for Medication Cart B did not match.

3. Review of the facility document titled Assure Platinum Blood Glucose Monitoring System: Quality Control

Record for April 2025 and the glucometers for Medication Carts A and B showed the quality control checks were not performed from 4/16 to 4/22/25. LVN 4 stated the quality control checks should be performed to ensure the glucometer readings for the residents' blood sugars were accurate.

On 4/28/25 at 0925 hours, an interview was conducted with the DON. The DON stated the serial numbers on

the glucometer and the Quality Control Record should match. The DON also stated the glucometers were calibrated to ensure for an accurate blood sugar readings when the glucometers were used on the residents.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 69 555733

F-F689, example #2.

47746

3. On 4/21/25 at 0828 hours, during the initial tour of the facility, Resident 80 was observed with a midline catheter to the LUA with the dressing dated 4/17/25. Resident 80 stated he was receiving two different types of antibiotic medications in the facility due to a bone infection to his left foot.

Medical record review for Resident 80 was initiated on 4/21/25. Resident 80 was admitted to the facility on [DATE REDACTED].

Review of Resident 80's H&P examination dated 3/13/25, showed Resident 80 had the capacity to understand and make decisions.

Review of Resident 80's plan of care showed a care plan problem dated 3/21/25, addressing Resident 80's RUA PICC line use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0656 Review of Resident 80's Midline Insertion Record dated 4/17/25, showed the LUA midline catheter was inserted because the previous IV access on the RUE was infiltrated (occurs when the fluids or medications Level of Harm - Minimal harm or intended to be delivered into a vein leak into the surrounding tissue instead of the bloodstream) and came potential for actual harm out of the resident's arm.

Residents Affected - Few Further review of Resident 80's plan of care failed to show a care plan problem addressing the resident's LUA midline catheter inserted on 4/17/25.

On 4/23/25 at 0938 hours, an observation and concurrent interview was conducted with Resident 80. Resident 80 was observed with a midline catheter to the LUA. Resident 80 stated he accidentally pulled out

the previous IV access on his RUA when he was putting on his sweater sleeve. Resident 80 further stated

the facility staff immediately responded and a licensed nurse from an outside company placed a midline catheter to his LUA on 4/17/25.

On 4/23/25 at 0958 hours, an interview and medical record review was conducted with RN 1. RN 1 verified Resident 80's IV access was changed to a LUA midline catheter on 4/17/25, and there was no care plan developed to address the resident's LUA midline catheter.

On 4/23/25 at 1108 hours, an interview and medical record review was conducted with the DON. The DON verified there was no care plan developed to address Resident 80's LUA midline catheter use.

On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide Residents Affected - Few the necessary care and services to maintain the highest physical well-being for two of 35 final sampled residents (Residents 44 and 77).

* The facility failed to ensure the TLSO brace was applied to Resident 44 as per the physician's order.

* The facility failed to ensure Resident 77's physician was notified when the resident had the blood sugar levels between 351- 400 mg/dL as ordered.

These failures had the potential to affect Resident 44 and 77's well-being.

Findings:

1. On 4/21/25 at 1034 hours, Resident 44 was observed lying in her bed and sleeping. There was a TLSO brace observed on her wheelchair.

Medical record review for Resident 44 was initiated on 4/21/25. Resident 44 was admitted to the facility on [DATE REDACTED].

Review of Resident 44's Order Summary Report dated 4/24/25, showed a physician's order dated 4/9/25, to apply the TLSO brace while up on the wheelchair; and may remove when in bed and during ADL care.

Review of Resident 44's plan of care showed a care plan problem dated 3/12/25, to address Resident 44's risk for falls. The intervention showed for the TLSO brace to be worn at all times while out of bed.

On 4/24/25 at 1007 hours, Resident 44 was observed to not be in her room; however, the TLSO brace was observed on top of the desk in her room.

On 4/24/25 at 1030 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 44 was in the activities room. LVN 2 stated Resident 44 used the TLSO brace due to a fracture of her T11 (a fracture located at the thoracic spine) and needed the brace on at all times when she was out of bed. LVN 2 was informed of the above findings. LVN 2 then checked Resident 44's room and verified the TLSO brace was not on Resident 44. Afterwards, LVN 2 walked to Dining Room B. Resident 44 was observed sitting in her wheelchair, without the TLSO brace on. LVN 2 then brought Resident 44 to her room and applied the TLSO brace on Resident 44.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0684 On 4/24/25 at 1317 hours, an interview and concurrent medical record review was conducted with the DOR.

The DOR stated Resident 44 had a vertebral (spinal) fracture and required a TLSO brace. The DOR stated Level of Harm - Minimal harm or the TLSO was recommended by the orthopedic surgeon for the resident to wear for fractures. The DOR potential for actual harm stated the TLSO brace prevented for turning or twisting at the spine and maintained an upright posture. The DOR was informed and acknowledged the above findings. The DOR stated Resident 44's physician's order Residents Affected - Few showed for the resident to have the TLSO brace on while up in the wheelchair.

On 4/28/25 at 0851 hours, an interview and concurrent medical record review was conducted with the DON and Nurse Consultant. The DON and Nurse Consultant were informed and acknowledged the findings.

47474

2. Medical record review for Resident 77 was initiated on 4/22/25. Resident 77 was admitted to the facility on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED].

Review of Resident 77's quarterly MDS assessment dated [DATE REDACTED], showed Resident 77 with a BIMS score of 13, which indicated the resident was cognitively intact.

Review of Resident 77's Order Summary Report for April 2025 showed the following physician's order:

- dated 7/6/23, to administer Novolin R (medication to lower blood sugar) Injection Solution 100 unit per ml subcutaneously before meals and at bedtime per the sliding scale as follows:

* if the blood sugar level less than 70 mg/dL, give orange juice and/or cookies; and if unresponsive or remains less than 70 mg/dL, give glucagon (medication to increase blood sugar) one mg IM one time and call the MD,

* for blood sugar level of 70 to 150 mg/dL, give zero units of insulin,

* for blood sugar level of 151 to 200 mg/dL, give three units of insulin,

* for blood sugar level of 201 to 250 mg/dL, give six units of insulin,

* for blood sugar level of 251 to 300 mg/dL, give nine units of insulin,

* for blood sugar level of 301 to 350 mg/dL, give 12 units of insulin, and

* for blood sugar level of 351 to 400 mg/dL, give 15 units of insulin and call the MD.

Review of Resident 77's MAR for April 2025 showed Resident 77's blood sugar levels were between 351 to 400 mg/dL and had received 15 units of Novolin R insulin at 1630 hours, on the following dates:

- on 4/3/25, the blood sugar level was 382 mg/dL.

- on 4/10/25, the blood sugar level was 361 mg/dL.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 0684 Further review of Resident 77's medical record showed no documented evidence Resident 77's physician was notified when the resident's blood sugar levels were between 351 to 400 mg/dL as per the physician's Level of Harm - Minimal harm or order. potential for actual harm

On 4/25/25 at 1516 hours, an interview and concurrent medical record review was conducted with LVN 4. Residents Affected - Few LVN 4 verified the above findings. LVN 4 stated the physician should have been notified for the blood sugar readings above 351 mg/dL as per the physician's order. LVN 4 further stated there was no documented evidence Resident 77's physician was notified of the elevated blood sugar readings on 4/3 and 4/10/25.

On 4/28/25 at 0925 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified the above findings. The DON stated she expected the license nurses to call the resident's physician if the blood sugar level was between 351 to 400 mg/dL as ordered. The DON verified there was no documented evidence Resident 77's physician was notified of the elevated blood sugar levels on 4/3 and 4/10/25. The DON stated the physician should have been notified of the resident's elevated blood sugar levels so the physician could adjust the resident's insulin orders appropriately.

On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant.

The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39683

Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 13) and one nonsampled resident (Resident 40) remained free from accidents and hazards.

* Resident 40's room had items cluttered on multiple surfaces of her room, including the floor. This failure had the potential for injury related to resident care and obstacles when a quick and safe evacuation of the resident was needed in an emergency.

* The facility failed to ensure Resident 13 was evaluated to determined if the resident required supervision and could safely store their own e-cigarette.

These failures had the potential to put the residents at an increased risk for serious injuries and negative health outcomes.

Findings:

1. Review of the facility's P&P titled Free of Accident Hazards/Supervision/Devices revised January 2025 showed the following:

- The facility will provide an environment free from accident hazards including in the resident's environment that have the potential to cause injury. The facility will identify, evaluate and analyze the hazards and risks and will implement an individualized, resident centered interventions.

Medical record review for Resident 40 was initiated on 4/21/25. Resident 40 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 40's Social Services progress note dated 7/17/24 at 1514 hours, showed Social Services Staff 1 and the CEO (previous Administrator) met with the resident. The resident had five bedside tables scattered around the resident's room with personal belongings on them. Social Services Staff 1 informed the resident she could only have one tray table for her use, just like the other residents in the facility. Social Services Staff 1 offered to assist the resident in organizing her belongings, and the resident became agitated, yelled, cursed, and used inappropriate name calling towards Social Services Staff 1.

Review of the Social Services progress note dated 4/16/25 at 1645 hours, showed Social Services Staff 2 and the Ombudsman met with Resident 40 at her bedside. The Ombudsman expressed concerns regarding

the amount of resident belongings in the resident's room and bed. The Ombudsman suggested if some of

the clutter could be relocated to enable the licensed nurses and CNAs to provide better care, but the resident refused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 On 4/24/25 at 1010 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 40 did not like

the facility staff going into her room or touching her belongings. The CNA stated the resident had a lot of Level of Harm - Minimal harm or belongings around the bed and room, and if the items were in the CNA's way, the resident did not like the potential for actual harm facility staff moving them.

Residents Affected - Few On 4/24/25 at 1015 hours, an interview was conducted with LVN 12. LVN 12 stated Resident 40 had a lot of belongings in her room and it was a hazard. LVN 12 stated the resident did not like the facility staff going into her room, unless she called them with the call light.

On 4/24/25 at 1026 hours, an interview and concurrent medical record review was conducted with the SSD.

The SSD stated Resident 40's hoarding (mental health condition characterized by acquiring and retaining a large number of possessions) had gotten worse, but the resident did not want the facility staff to touch her belongings. The SSD stated Social Services Staff 1 used to be the assigned Social Services staff, but the resident refused her and now Social Services Staff 2 was assigned to the resident.

On 4/24/25 at 1033 hours, an interview was conducted with Social Services Staff 2. Social Services Staff 2 stated he was been assigned to Resident 40 for about two weeks; and when he met with the resident, she would get upset when she was asked to move her belongings.

On 4/24/25 at 1044 hours, an interview was conducted with Social Services Staff 1. Social Services Staff 1 stated Resident 40 got upset with her and refused her as her assigned Social Services staff, so a new one Social Services staff was assigned. Social Services Staff 1 stated the facility purchased a small storage shelf for the resident to use, but the resident refused it.

On 4/24/25 at 1048 hours, an interview was conducted with the DON. The DON stated the facility spoke to Resident 40 on multiple occasions about her hoarding, but the resident refused to do anything. The DON stated the resident was not currently being followed by a consultant psychiatrist or psychologist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 On 4/24/25 at 1428 hours, an observation and concurrent interview was conducted with Social Services Staff 2 at Resident 40's bedside. Upon entering the room, the resident was observed in bed, with three bedside Level of Harm - Minimal harm or tables, one on each side of the bed and the third one over the foot of the bed. A nebulizer machine and food potential for actual harm items were on one tray table, and two water pitchers with straws were on another table. All three bedside tables were covered with multiple items. On the floor, at the foot of the bed was a wash basin filled with nail Residents Affected - Few polish, and boxes on the floor. A TV was sitting on a stand pulled away from the wall. Boxes and storage containers were on the floor around and behind the TV stand. A case of cup of noodles was on a stack of items at the back corner of the room. Delivery boxes and items were stacked along the entire wall to the left side of the resident; and behind the TV stand, a wheelchair was observed with items stacked on the seat.

The bed frame for a potential roommate did not have a mattress on it, and there were belongings stacked on

the bed frame. Social Services Staff 2 informed the resident the facility arranged a psychiatry consult for next week, and the resident stated she was glad because she was not doing good and one inch away from a breakdown. The resident stated she was aware that her clutter was an issue, but just thinking about it brought up a lot of emotions and she became overwhelmed. The resident expressed having multiple losses over the past few years and had a difficult time coping. The resident stated she also used online shopping as

a coping mechanism and had packages that she had not even opened yet. The resident expressed she was open to meeting with the psychiatrist and hopeful that she could address any issues and work with the facility staff on the clutter and creating safer environment.

On 4/28/25 at 0805 hours, an interview was conducted with CNA 9. When asked if Resident 40's clutter got

in the way of performing the resident's cares safely, CNA 9 stated it was difficult, but doable.

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2. Review of the facility's P&P titled Electronic Cigarette (e-Cigarette) revised 1/2024 showed the following:

- Facility will recognize the residents' rights to use e-Cigarettes; however, this right is strictly in accordance with the interdisciplinary team assessment of a resident's ability to smoke safely, in a designated smoking area.

- To promote the safety of the smoking resident, the IDT may require a resident to smoke under direct supervision. Residents are responsible for providing all smoking materials. Such materials will be labeled and maintained in a safe area by facility staff.

- E-cigarettes or vaping material(s) for residents requiring supervision will be labeled and kept at the nurses' station. Residents may ask for their vape materials prior to vaping in designated smoking areas.

- Residents evaluated by the nurse and reviewed by the IDT as independent through a smoking assessment; and who wish to maintain their own vape materials, may do so only when able to indicate the understanding vape materials are for individual use only and may not be shared with other residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 69 555733 Department of Health & Human Services Printed: 08/28/2025 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 555733 B. Wing 04/28/2025

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

The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835

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 On 4/21/25 at 1054 hours, an observation and concurrent interview was conducted with Resident 13 in Resident 13's room. Resident 13 stated he would go and use the vape (inhaling aerosol from an electronic Level of Harm - Minimal harm or cigarette) outside of the facility building and carried his vaping device with him. Resident 13 was observed potential for actual harm pulling out a vaping device from a pouch attached to the left side of his wheelchair. Resident 13 stated he kept his vaping device with him, unless he knew he would not be using it, or at nighttime. Residents Affected - Few Medical record review for Resident 13 was initiated on 4/21/25. Resident 13 was readmitted to the facility on [DATE REDACTED].

Review of Resident 13's H&P examination dated 4/4/25, showed Resident 13 had the capacity to understand and make decisions.

Review of Resident 13's Smoking Risk assessment dated [DATE REDACTED], showed Resident 13 was safe to smoke, could light his own cigarette, and did not have any limitations which would impact his ability to smoke. The section for additional information showed Resident 13 was observed using a vape (electronic cigarette).

Further review of the medical record for Resident 13 failed to show if Resident 13 was thoroughly assessed and evaluated to determine if he required supervision during smoking and if he could safely store his own smoking materials.

On 4/24/25 at 1023 hours, an observation, interview, and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 13 used a nicotine vaping device and would use it independently. LVN 2 stated he kept Resident 13's vaping device in the narcotic drawer when the resident was not using it. LVN 2 stated Resident 13 had his vaping device on him right now, but the resident was not able to keep it with him. LVN 2 stated he needed to ask for the vaping device back from Resident 13.

On 4/24/25 at 1328 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified Resident 13 used an e-cigarette. The DON stated for the residents who smoke, the facility completed a smoking assessment and developed a care plan. The DON verified the Smoking Risk Assessment nor the IDT assessment did not include if Resident 13 was assessed to be able to smoke without supervision or if he could safely store his smoking materials.

Cross reference to