Sunray Healthcare Center

F-F759)

-Ensure the Controlled Drug Record form (CDR, an accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR, a log initialed and/or signed by the nurse with the date and time each time a medication is administered to a resident) for an administered dose of a controlled medication, (Oxycodone/acetaminophen [APAP] is a combination medicine used to help treat severe pain) 10 mg per 325 mg [10-325 mg] on 3/28/2025 at 8:20 PM for Resident 80.

-Ensure an accurate accountability of the inventory of a controlled medication Ativan (Lorazepam, use to treat seizures, a sudden, temporary disruption of normal brain activity) 20 mg per 10 milliliter (ml, unit of measurement by volume) was maintained at all times including delivery to the facility and administration of

the medication to Resident 18.

-Ensure Resident 18 was reassessed for effectiveness of as needed (PRN) when administered Ativan for seizure control within 30 minutes and not over 15 hours later.

-Ensure the prescription label, the Medication Administration Record (MAR) and the current physician's order matched for Resident 18's controlled medication, Ativan.

-Ensure Resident 6 and Resident 73 had rotation of injection sites for insulin administration.

These deficient practices had the potential for discoloration of skin and hardening of the injection sites for Resident 6 and Resident 73, created the potential for unsafe medication administration of necessary medications to Resident 80 and Resident 18, had the potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications, and resulted in an increased risk for inaccurate reconciliation of controlled medications in the facility.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 a. A review of Resident 80's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension (HTN, high blood pressure), dependence on respiratory (ventilator, Level of Harm - Minimal harm or relies on a machine to breathe and cannot breathe independently) status, and gastrotomy tube (G-tube, a potential for actual harm surgically placed tube that provides direct access to the stomach for feeding, hydration, or medication administration). Residents Affected - Some

During a review of Resident 80's Minimum Data Set (MDS - a resident assessment tool) dated 3/27/2025 indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact and the resident required between moderate to totally dependent on staff for activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a medication pass observation on 4/21/2025, between 11:33 AM to 12:14 PM for Resident 80, with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed preparing and administering one tablet of Amlodipine 5 mg crushed, dissolved in water and given through a G-tube to the resident. LVN 2 was not observed checking Resident 80's BP prior to the administration of the BP medication.

During an interview on 4/21/2025 at 12:20 PM, LVN 2 stated there was a timeframe to give medications and Resident 80's scheduled 9 AM medications was to be administered by 10 AM. LVN 2 stated, I have not notified my supervisor that I was running behind, and I have not called or informed the doctor yet. LVN 2 stated the Registered Nurse Practitioner (NP 1) was at the facility and had not been notified.

During an interview on 4/21/2025 at 12:39 PM, LVN 2 stated she checked Resident 80's BP at 8:04 AM, on 4/21/2025 at the start of her shift, but had not checked Resident 80's BP before administering the resident's BP medication, Amlodipine at 12:19 PM (four hours later).

A review of Resident 80's April 2025 Physician's Order Summary Report indicated:

-Amlodipine Oral Tablet 5 mg, dated 12/23/2024, give one tablet via G-Tube one time a day (scheduled administration at 9 AM) for hypertension. Hold for systolic blood pressure (SBP, when the heart contracts and pumps blood) less than 110 millimeters of mercury (mmHg) or heart rate (HR, the number of times the heart beats per minute [bpm]) less than 60 bpm.

-Metoprolol Tartrate 50 mg, dated 12/23/2024, give one tablet via G-tube every eight hours (scheduled administration at 6 AM, 2 PM, and 10 PM) for HTN. Hold for SBP less than 110 mm Hg or HR less than 60 bpm.

During a review of Resident 80's Medication Administration Audit Report dated between 4/7/2025 to 4/21/2025, indicated the resident was administered Amlodipine scheduled daily at 9 AM late on a total of six occasions as follow:

4/12/25 scheduled at 9 am, documented administered at 11:06 am

4/13/25 scheduled at 9 am, documented administered at 12:58 pm

4/14/25 scheduled at 9 am, documented administered at 11:16 am

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 4/17/25 scheduled at 9 am, documented administered at 12:04 pm

Level of Harm - Minimal harm or 4/19/25 scheduled at 9 am, documented administered at 10:38 am potential for actual harm 4/21/25 scheduled at 9 am, documented administered at 12:19 pm Residents Affected - Some

During a concurrent interview and record review on 4/21/2025 at 3:56 PM, with the Director of Nursing (DON), Resident 80's April 2025 Physician's Orders was reviewed and indicated resident's Metoprolol Tartrate 50 mg, had a 2 PM scheduled administration time. The DON stated if another medication was due soon after the late medication (Amlodipine) was administered, there could be an overlap of BP medications and the effect of the combined BP medications could have a greater effect on the resident that could lead to

a confusion, lethargy (sleepiness), or a stroke (occurs when blood flow to the brain is interrupted). The DON stated if medications were not given as scheduled, the physician should be notified.

During an interview on 4/23/2025, at 2:41 PM, the facility's Medical Director (MDR) stated the physician should have been informed if Resident 80 received medications later than scheduled. The MDR stated the reason for checking the resident's BP before giving the BP medication was to ensure the licensed nurse follows the parameters that were listed on the physician's order.

During a review of the facility's P&P titled, Administering Medications, revision date 4/2019 indicated medications were administered in a safe and timely manner, and as prescribed. Staffing schedules were arranged to ensure that medications were administered without unnecessary interruptions. Medications were administered in accordance with prescriber orders, including any required time frame. Medications were administered within one hour of their prescribed time, unless otherwise specified (for example, before and

after meal orders). The following information was checked / verified for each resident prior to administering medications .Vital signs if necessary.

b. A review of Subacute A, Medication Cart 3, on 4/23/2025 at 10:13 AM, with LVN 4, indicated Resident 80's CDR for Oxycodone/APAP 10-325 mg had one tablet removed from the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) on 3/28/2025 at 8:20 PM. The MAR indicated the licensed nurse's initials or documentation to indicate the resident was administered the dose of Oxycodone/APAP 10-325 mg on 3/28/2025 at 8:20 PM was missing. During a concurrent interview, LVN 4 stated Resident 80's administration of Oxycodone / APAP 10-325 mg was not documented on the MAR on 3/28/2025, but was documented on the CDR on 3/28/2025 at 8:20 PM. LVN 4 stated when the licensed nurse removed the Oxycodone/APAP 10-325 mg from the medication card for Resident 80, the nurse should have signed on the CDR for the removal of the medication and signed on the MAR after the medication was administered to the resident.

During a review of Resident 80's March 2025 Physician's Order Summary Report, the report indicated a physician's order for Oxycodone/APAP Oral Tablet 10-325 mg, with instructions to give one tablet via G- Tube every 8 hours as needed for moderate to severe pain 4-10 (using a Pain Scale of 0-10, 0 indicating no pain and 10 indicating most severe pain). The report indicated to hold if drowsy or respiratory rate (RR, the number of breaths a person takes per minute) below 12 and notify MD (physician).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 During a concurrent interview and record review on 4/23/2025 at 11:18 AM, with Licensed Vocational / Quality Assurance Nurse (LVN 5), Resident 80's pain assessment, MAR, CDR, and nursing progress notes Level of Harm - Minimal harm or were reviewed. LVN 5 stated the initials on the CDR was from a Registry (temporary nurse) LVN (LVN 6). potential for actual harm LVN 5 stated LVN 6 did not document on Resident 80's MAR the administration of Oxycodone/APAP 10-325 mg and did not document on the MAR or in the nursing progress notes a pain assessment for the resident to Residents Affected - Some determine the resident's level of pain prior to administering the pain medication or the effectiveness of the medication. LVN 5 stated not documenting on the MAR increased the risk for medication errors and drug (medication) diversion.

During an interview on 4/23/2025 at 3:01 PM, the facility's Medical Director (MDR) stated licensed nurses should have documented the administration of Oxycodone/APAP 10-325 mg for Resident 80 on the MAR to verify that the medication was pulled and administered to the resident.

During a review of the facility's undated policy and procedure (P&P) titled, Documentation of Medication Administration, the P&P indicated A medication administration record is used to document all medications administered. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's MAR. Administration of medication was documented immediately after it was given. Documentation of medication administration includes, as a minimum, initials, signature and title of the person administering the medication, resident response to the medication, if applicable (e.g., PRN, pain medication, etc.).

c. During a review of Resident 18's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included epilepsy ( a brain condition that causes repeated seizures), anoxic brain damage (brain injury resulting from a complete lack of oxygen supply, causing serious damage or death to brain cells), dependence on respiratory (ventilator), and G-Tube

A review of Resident 18's MDS dated [DATE REDACTED] indicated the resident was in a persistent vegetative state (PVS, an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). Resident 18's MDS indicated the resident was totally dependent on staff for activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During concurrent interview and record review of Subacute A, Medication Cart 3, on 4/23/2025 at 10:20 AM, with LVN 4, Resident 18's CDR, MAR, Medication Administration Detail, physician's order, and pharmacy label for Resident 18's Ativan 2 mg/ ml injectable medication were reviewed, and the following discrepancies were observed:

-Resident 18's CDR was handwritten that included the resident's name, the name of the medication, Ativan injection solution 2 mg/ ml, the route of administration, IM, and a starting quantity of 7 ml and an ending quantity of 6 ml. LVN 4 stated the instructions on the CDR form for Resident 18's Ativan was missing instructions for use and the pharmacist prescription label.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 -Resident 18's Medication Administration Detail, for April 2025 indicated the resident was administered two doses of Ativan 2 mg/ml, injection of 0.5 ml (1 mg) on 4/12/2025 at 4:30 PM and follow up on 4/12/2025 at Level of Harm - Minimal harm or 4:32 documentation indicated, Effective and on 4/12/2025 at 4:41 PM and follow up on 4/13/2025 at 7:56 AM potential for actual harm documentation indicated, Effective (15 hours later). LVN 4 stated Resident 18 should have been reassessed 30 minutes after the PRN administration of Ativan and not the next day. LVN 4 stated part of the Residents Affected - Some documentation within 30 minutes is to monitor the effectiveness of the medication administered to Resident 18 for seizure control.

-Resident 18's April 2025 Physician's Order Summary Report included a physician's order for Ativan (Lorazepam) Injection Solution 2 mg/ml, instructions indicated to inject 0.5 ml (1 mg) intramuscularly (medication administered into a muscle) every 10 minutes as needed for seizure activity, order dated 4/8/2025. LVN 4 stated Resident 18's physician's order was missing a maximum dose. LVN 4 stated the physician's order was incomplete and the licensed nurse should have called the doctor to have the order for Ativan clarified. LVN 4 stated Resident 18's Ativan, physician's order was missing the maximum dose to give

before calling the physician. LVN 4 stated Resident 18 was receiving Ativan for seizures, if the medication was not effective for the seizures the resident would need to be sent out by calling 911 (an emergency situation that requires immediate assistance from the police, fire department or ambulance) and transfer to

the hospital for uncontrolled seizures. LVN 4 stated there was nothing on the order to indicated when to call

the physician.

-Resident 18's Ativan prescription label dated 8/26/2024, instructions for use indicated to administer 1 ml (2 mg) of Ativan 2 mg/ ml every 10 minutes as needed for seizure disorder. LVN 4 stated the Ativan prescription labeled for Resident 18's was incorrect, and the current physician's order dose had decreased to 0.5 ml (1 mg) of Ativan 2 mg/ ml every 10 minutes as needed. The Ativan prescription bottle indicated 2 mg/ml quantity of 10 ml. The CDR indicated a starting quantity of 7 ml. LVN 4 could not explain the 3 ml discrepancy in quantity of the controlled medication, Ativan 2 mg/ml.

During a concurrent interview and record review on 4/23/2024 at 11:48 AM, with NP 1, Resident 18's April 2025, CDR, MAR, and nursing progress notes were reviewed. NP 1 stated Resident 18's licensed nurse should have documented the follow-up 30 minutes after the PRN dose of Ativan was administered by injection to Resident 18. NP 1 stated the reassessment of Resident 18 was to check if the resident was having another seizure that may require the facility to call 911 and send the resident out to the hospital to prevent a delay in care for seizure control.

During an interview on 4/23/2024 at 11:55 AM, LVN 5 stated Resident 18's Ativan 2 mg/ml 10 ml vial had not been updated from the old instructions to administer Ativan 1 ml (2 mg) to the current order to administer Ativan 0.5 ml (1 mg), which could lead to medication errors or drug diversion.

During an interview on 4/23/2025 at 1:12 PM, NP 1 stated Resident 18's Ativan 2 gm/ml order should have been clarified, and a new prescription should have been sent to the facility, or a note should have been attached to the prescription label to indicate a direction change with clear instructions for use.

During an interview on 4/23/2025 at 3:12 PM, the MDR stated for Resident 18's Ativan 2 mg/ml the order should have been clarified to indicate how many doses to give and when to call the doctor and or call 911, because treatment may change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 During a review of the facility's P&P titled, Controlled Medication Storage, effective date 8/2014, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled Level of Harm - Minimal harm or substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance potential for actual harm with federal, state and other applicable laws and regulations. A controlled medication accountability record was prepared by the pharmacy or facility for all Schedule Il-V medications. The following information was Residents Affected - Some completed:

1) Name of resident

2) Prescription number

3) Name, strength, and dosage form of medication

4) Date received

5) Quantity received

6) Name of person receiving medication supply

7) Dispensing pharmacy information .

Any discrepancy in controlled substance medication counts was reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. The director of nursing in conjunction with consultant pharmacist or designee routinely monitors controlled medication storage, records, and expiration dates during medication storage inspections.

d. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnoses including Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anoxic brain damage (a type of brain injury that occurs when the brain is completely deprived of oxygen), and paraplegia (loss of movement and/or sensation, to some degree, of the legs).

During a review of Resident 6's MDS dated [DATE REDACTED], the MDS indicated the resident was not oriented to person, place, or time. The MDS indicated Resident 6 had poor recall and was either dependent and needed substantial/maximal assistance with eating, dressing, hygiene, showering, and toileting.

During a review of Resident 6's Diabetes Mellitus Care Plan dated 4/2/2025, the Care Plan indicated in the interventions to rotate the injections sites.

During a review of Resident 6's Location of Administration Record dated 4/2025, the Administration Record indicated Resident 6 received Novolin R injection in the same injection sites on the following dates:

-4/2/2025 - subcutaneously (situated or applied under the skin) - Abdomen left upper quadrant (LUQ - located on the left side of the abdomen, above the navel), at 4 PM and 9 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 -4/7/2025 - subcutaneously - Abdomen right upper quadrant (RUQ - located on the right-side abdomen, above the navel), at 11:30 AM and 4:30 PM. Level of Harm - Minimal harm or potential for actual harm -4/11/2025 and 4/12/2025 - subcutaneously - Abdomen left lower quadrant (LLQ - located on the left side of

the abdomen, below the navel). Residents Affected - Some -4/19/2025 - subcutaneously - Abdomen LLQ at 12:22 PM and 11:01 PM.

e. During a review of Resident 73's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnoses including Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and aphasia (a disorder that makes it difficult to speak).

During a review of Resident 73's MDS dated [DATE REDACTED], the MDS indicated the resident was oriented to year and month. The MDS indicated Resident 73 had poor recall and had no symptoms of feeling down, depressed, or hopeless.

During a review of Resident 73's Location of Administration Record dated 4/2025, the Administration Record indicated Resident 73 received Insulin Injection in the same injection sites on the following dates:

-4/6/2025 - subcutaneously - Abdomen LLQ at 05:32 AM and 12:22 PM.

-4/11/2025 and 4/12/2025 - subcutaneously - Abdomen LLQ.

-4/13/2025 - subcutaneously - Arm right at 11:37 AM and 5:34 PM.

-4/13/2025 and 4/14/2025 - subcutaneously - Abdomen LUQ.

-4/16/2025 - subcutaneously - Abdomen LUQ at 05:48 AM and 12:20 PM.

-4/19/2025 - subcutaneously - Arm - right at 11:11 AM and 8:20 PM.

-4/20/2025 - subcutaneously - Abdomen LLQ at 4:30 PM and 11:01 PM.

-4/21/2025 - subcutaneously - Abdomen LLQ at 05:41 AM.

During a concurrent interview and record review on 4/23/2025 at 12:15 PM with LVN 3, Resident 6 and 73's Location of Administration Record dated 4/2025 were reviewed. LVN 3 reviewed on several days both residents received their insulin injections in the same sites on multiples days hours from the last injection. LVN 3 stated that the nurses should be rotating injections sites each time an injection was given. LVN 3 stated the policy indicated the nurses should be rotating sites. LVN 3 did not confirm that the policy indicated injection sites could be administered per the resident's preference. LVN 3 stated the risk these residents could be discoloration and hardened areas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 During an interview on 4/23/2025 at 12:25 PM, the Director of Nursing (DON) stated the nurses should be rotating injection sites each time an injection was given. The DON stated she was unsure if the policy Level of Harm - Minimal harm or indicated that the injection sites could be administered per resident preference. potential for actual harm

During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, dated 8/30/24, the Residents Affected - Some P&P indicated that injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 43851

Residents Affected - Few Based on interview and record review, the facility failed to clarify the physician's orders for hydrocortisone cream (a topical steroid cream applied to the skin to reduce inflammation, redness, itching and swelling) as recommended by the facility's consultant pharmacist (a healthcare professional, who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications)

during the Monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes

a resident's medication list, ensuring that the medications are appropriate, effective, and safe) dated 1/13/2025, for one of three sampled residents (Resident 49) reviewed for Unnecessary Medications and Medication Regimen Review.

This deficient practice had the potential for Resident 49 to experience adverse effects (undesired and harmful effects that occur because of a medication, treatment, or procedure) from hydrocortisone cream such as skin thinning, skin irritation and/or skin infection.

Findings:

During a review of Resident 49's Admission Record, the Admission Record indicated the facility readmitted

the resident on 9/12/2024 with diagnoses that included Type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), rash (an abnormal skin condition, often characterized by redness, irritation, bumpy, or itchy skin), schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality).

During a review of Resident 49's physician's order dated 9/12/2024, the order indicated the resident was to receive 1 % hydrocortisone cream to the right side of his nose and face every 6 hours as needed for itching.

The physician's order for 1% hydrocortisone cream had no end date and could be used indefinitely (for an unlimited or unspecified period of time).

During a review of the facility's document titled, Consultant Pharmacist's Medication Regimen Review, dated 1/13/2025, the document indicated Resident 49 had an order for hydrocortisone cream without a stop date.

The MRR indicated a recommendation to use a topical steroid for no more than four weeks at a time. The MRR indicated for facility staff to ask Resident 49's physician to include a stop date in the order of or discontinue the resident's hydrocortisone cream.

During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool) dated 4/7/2025, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS further indicated Resident 49 was applying ointment/medications to areas other than the feet for skin treatments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 0756 During a concurrent interview and record review on 4/23/2025 at 2:20 PM, Resident 49's physician's order for hydrocortisone cream dated 9/12/2024 and the facility's document titled Consultant Pharmacist's Level of Harm - Minimal harm or Medication Regimen Review, dated 1/13/2025 were reviewed with Licensed Vocational Nurse (LVN) 5. LVN potential for actual harm 5 verified and confirmed the consultant pharmacist recommended to put a stop date or discontinue Resident 49's physician order for hydrocortisone cream. LVN 5 stated Resident 49's current physician's order for Residents Affected - Few hydrocortisone was indefinite and had no stop date. LVN 5 stated when the consultant pharmacist made a recommendation, the resident's physician had to be notified of the recommendation. LVN 5 stated Resident 49's physician's order should have been clarified with the resident's physician as recommended by the consultant pharmacist. LVN 5 stated consultant pharmacist recommendations had to be followed to help prevent the resident from having unwanted side effects.

During a concurrent interview and record review on 4/24/2025 at 9:02 AM, Resident 49's physician's order for hydrocortisone cream dated 9/12/2024 and the facility's document titled Consultant Pharmacist's Medication Regimen Review, dated 1/13/2025 were reviewed with the Director of Nursing (DON). The DON verified the facility's pharmacy consultant recommended to put a stop date or discontinue Resident 49's physician's order for hydrocortisone cream on 1/13/2025. The DON stated Resident 49's current physician's order for hydrocortisone cream did not have a stop date. The DON did not know why Resident 49's physician's order for hydrocortisone cream was not discontinued or clarified.

The DON stated that when the pharmacist recommended changes to the residents' medication, the recommendations had to be followed through because medications had adverse effects. The DON stated there could have been a potential for Resident 80 to experience adverse effects of the medication if the pharmacist recommendations were not followed. The DON stated following the pharmacist recommendations could help prevent the resident from experiencing adverse effects of medications.

During a review of the facility's policy and procedure titled, IIIA1: Medication Regimen Review (Monthly Report), reviewed 8/30/2024, the P&P indicated The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Resident-specific irregularities and/or clinical significant risks resulting from or associated with medications are documented and reported to

the DON, and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber .Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31333 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the facility's medication error Residents Affected - Few rate (observed or identified preparation or administration of medications or biologicals which was not in accordance with the physician's order, manufacturer's specifications for the preparation and administration of

the medication or biological, and professional standards of practice) was not five percent (5%) or greater. There were seven medication errors out of 28 opportunities (observations during medication administration) for error, to yield a cumulative error rate of 25 % for one of four sampled residents (Resident 80) observed

during the medication administration.

These deficient practices had the potential to result in harm to Resident 80 by not meeting the residents' individual medication and therapeutic needs (the specific types of treatments or interventions that are necessary to address a person's medical condition or improve their overall well-being).

Findings:

During a review of Resident 80's Admission Record, the admission record indicated Resident 80 was admitted to the facility on [DATE REDACTED] with diagnoses that included hypertension (HTN, high blood pressure), dependence on respiratory (ventilator, relies on a machine to breathe and cannot breathe independently) status, and gastrotomy tube (G-tube, a surgically placed tube that provides direct access to the stomach for feeding, hydration, or medication administration).

During a review of Resident 80's Minimum Data Set (MDS - a resident assessment tool) dated 3/27/2025,

the MDS indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident required between moderate to totally dependent

on staff for activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 80's April 2025 Physician's Order Summary Report, the report included the following physician's orders:

-Amlodipine (use to treat hypertension [HTN], high blood pressure), Oral Tablet 5 mg, dated 12/23/2024, administer one tablet via G-Tube once per day (9 AM) for HTN. Hold for Systolic Blood Pressure (SBP, when

the heart contracts and pumps blood) less than 110 millimeters of mercury (mmHg) or Heart Rate (HR) - the number of times the heart beats per minute [bpm]) less than 60 bpm.

-Vitamin D3 Oral Capsule 125 mcg (5000 IU), dated 1/21/2025, give one capsule via G-Tube once a day (9 AM) for Vitamin D deficiency.

-Ferrous Sulfate (helps red blood cells carry oxygen to tissues and organs) Oral Solution 220 mg/5 ml, dated 4/4/2025, give 7.5 ml via G-Tube once a day (9 AM) for Anemia Give 7.5 ml=330 mg. Shake bottle well.

-Folic Acid (helps prevent anemia, low red blood cells), Oral Tablet 1 mg, dated 12/23/2024, give one tablet via G-Tube once a day (9 AM) for Supplement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 0759 -Senokot (Sennosides, used to treat constipation) Oral Tablet 8.6 mg, dated 12/23/2024, give two tablets (17. 2 mg) via G-Tube every 12 hours (9 AM and 9 PM) for Bowel Management. Hold for loose stool. Level of Harm - Minimal harm or potential for actual harm -Vitamin B12 Oral Tablet (Cyanocobalamin), dated 4/4/2025, give 1000 mcg via G-Tube once a day (9 AM) for Vitamin B12 deficiency. Residents Affected - Few -Vitamin C Oral Liquid 500 mg /5 ml (Ascorbic Acid), dated 3/26/2025, give 5 ml via G-Tube once a day (9 AM) for Supplement.

-Cranberry Oral Tablet 450 MG, dated 1/21/2025, give one tablet via G-Tube once a day (9 AM) for UTI, prophylactically (to prevent).

During an observation of medication administration for Resident 80 on 4/21/2025, between 11:33 AM to 12:14 PM, Licensed Vocational Nurse (LVN) 2 was observed preparing the above medications for the 9 AM scheduled medication administration via G-tube.

During an interview on 4/21/2025, at 11:33 AM, LVN 2 stated the medications prepared for Resident 80 were to be administered at 9 AM and should have been given to Resident 80 by 10 AM. LVN 2 confirmed a total of eight morning medications were prepared for the resident.

During an observation in Resident 80's room on 4/21/2025 at 12 PM, Resident 80 was observed awake, alert, and responded to LVN 2 by nodding his head. LVN 2 administered each medication via the residents' G-tube one by one, flushing with water before and in between each medication, and after completion of the medication administration. LVN 2 was not observed checking the resident's blood pressure or heart rate prior to administering the blood pressure medication, Amlodipine.

During an interview on 4/21/2025 at 12:20 PM, LVN 2 stated, I have not notified my supervisor that I was running behind, and I have not called or informed the doctor yet. LVN 2 stated the Registered Nurse Practitioner (NP 1) was at the facility and had not been notified yet.

During a concurrent interview and record review, on 4/21/2025 at 12:33 PM with NP 1, Resident 80's blood pressure (BP), heart rate, nursing progress notes, and medication administration records were reviewed for 4/21/2025. Resident 80's BP was documented at 8:04 AM on 4/21/2025 as 138 mmHg/80 mmHg (systolic pressure, top number measures the pressure in the arteries when the heart beats; diastolic pressure, bottom number measures the pressure in the arteries between heartbeats. Normal blood pressure is below 120/80 mmHg). NP 1 stated the licensed nurse (LVN 2) should have checked Resident 80's BP before administering

the BP medication, Amlodipine, because the licensed nurse needed to know the resident's BP and HR

before giving the BP medications.

NP 1 stated the licensed nurse (LVN 2) should not give BP medication based on BP or HR taken hours earlier as the vital signs (reflect essential body functions, including the heartbeat, breathing rate, temperature, and blood pressure) might not have been accurate. NP 1 stated administering Resident 80's Amlodipine too close to the next scheduled BP medication, Metoprolol, scheduled for administration at 2 PM, could cause a drop in the resident HR and cause bradycardia (a heart rate that is slower than normal, generally defined as less than 60 beats per minute (bpm) for adults). NP 1 stated that was the reason the medications (Amlodipine and Metoprolol) were scheduled at different times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 0759 During an interview on 4/21/2025 at 12:39 PM, LVN 2 stated she checked Resident 80's BP at 8:04 AM on 4/21/2025 at the start of her shift but had not checked Resident 80's BP before administering the resident's Level of Harm - Minimal harm or BP medication, Amlodipine at 12:19 PM (four hours later) on 4/21/2025. potential for actual harm

During an interview on 4/21/2025 at 12:39 PM, Registered Nurse (RN) 1 stated LVN 2 should have informed Residents Affected - Few her that LVN 2 was running late during medication pass before passing the 9 AM medications to Resident 80. RN 1 stated Resident 80's physician had to be informed to make sure there were no contraindications with other medications and to allow the physician to adjust medication administration as needed.

During an interview on 4/21/2025 at 3:56 PM, the Director of Nursing (DON) stated Resident 80's BP should have been taken prior to administering BP medications with a parameter (fixed high and low limits in which blood pressure must be to safely administer the medication) to determine when to give or hold a BP medication. The DON stated the facility's policy was to give residents their medications within one hour

before or after the scheduled administration time and the nurses had to inform the NP or physician if medications could not be administered on time.

During a concurrent interview and record review on 4/21/2025 at 3:56 PM, with the DON, Resident 80's April 2025 Physician's Orders were reviewed and indicated: Metoprolol Tartrate 50 mg, give one tablet via G-tube every eight hours (6 AM, 2 PM, and 10 PM) for HTN. Hold for SBP less than 110 mm Hg or HR less than 60 bpm, order dated 12/23/2024. The DON stated if another medication was due soon after the late medication was administered there could be an overlap of BP medications and the effect of the combined BP medications could have a greater effect on the residents that could lead to confusion, lethargy (sleepiness), or a stroke (occurs when blood flow to the brain is interrupted). The DON stated if medications were not given as scheduled, the physician had to be notified.

During an interview on 4/23/2025, at 2:41 PM with the facility's Medical Director (MDR), the MDR stated the physician should have been informed if Resident 80 was going to receive medications later than scheduled.

The MDR stated the reason for checking the resident's BP before giving the BP medication was to ensure

the licensed nurse followed the parameters that were listed on the physician's order.

During a review of the facility's policy and procedure titled, Administering Medications, revision date 4/2019 indicated medications were administered in a safe and timely manner, and as prescribed. Staffing schedules were arranged to ensure that medications were administered without unnecessary interruptions. Medications were administered in accordance with prescriber orders, including any required time frame. Medications were administered within one (1) hour of their prescribed time, unless otherwise specified (for example,

before and after meal orders). The following information was checked/verified for each resident prior to administering medications, vital signs if necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 38740

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure staff followed the Reduced Concentrated Sweets (RCS) diet for blood sugar control, according to the facility's food portioning and serving guide spreadsheet instructions. By failing to ensure residents on RCS diets did not receive garlic bread for lunch on 4/21/2025. This deficient practice could result in increased blood sugar levels for 13 of 64 residents who were on RCS diet.

Findings:

A review of the facility lunch menu for regular and RCS diets on 4/21/2025 indicated the following items were to be served: Regular diet: Spaghetti with meat sauce 1 cup, tossed salad with dressing 1 cup, garlic bread 1 each, Strawberry poke cake 1 square, and water. RCS diet: Spaghetti with meat sauce 1 cup, tossed salad with dressing 1 cup, strawberry poke cake 1/2 square, and water.

During an observation of the tray line service for lunch (a system of food preparation, in which trays move along an assembly line) on 4/21/2025 at 11:45 AM, both regular and RCS diets were observed receiving garlic bread.

During a review of the facility's lunch meal food portioning and serving guide spreadsheet, the spreadsheet indicated RCS diet was not to receive garlic bread.

During a concurrent observation and interview with Dietary Aide (DA) 2 on 4/21/2025 at 12:30 PM, DA 2 stated his job was to look at the diets and serve the side dishes such as salad, dessert and bread that went

on each resident tray along with the main meal. DA 2 confirmed by stating he added the bread and salad to

the trays. DA 2 stated regular diets received one square of strawberry poke cake and the RCS diet received 1/2 square of strawberry poke cake.

During a concurrent review of the spreadsheet and interview with DA 2 on 4/21/2025 at 12:35 PM, DA 2 stated residents on RCS diet should not have received garlic bread and confirmed the residents were served garlic bread. DA 2 stated serving garlic bread could affect blood sugar levels.

During an interview with the Dietary Supervisor (DS) and Registered Dietitian (RD) on 4/21/2025 at 1 PM,

the DS stated garlic bread should not have been served on the RCS diet. The DS stated portions and serving directions indicated on the spreadsheet had to be followed. The RD stated staff were to follow diet spreadsheets to make sure residents received the correct nutrition per diet orders.

A review of facility policy titled, Controlled-Carbohydrate Diet, revised 2/2025 indicated Controlled Carbohydrate Diet (CC) was used to achieve and maintain sugar control alone or in conjunction with medication. This diet may be appropriate for residents with diabetes or impaired glucose tolerance. In this diet, priority was given to the total amount of carbohydrates consumed at each meal and snack rather than to

the specific source of carbohydrate. Portion sizes on this menu must be followed. Consistent timing of meals and snacks was also important.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 38740

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to ensure resident cups, trays, and dishes were clean prior to removing from the dish machine and storing to air dry. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 64 out 69 residents who received food from the facility kitchen.

Findings:

During a concurrent observation and interview in the dish washing area, with Dietary Aide (DA) 1 and Dietary Supervisor (DS) on 4/21/2025 at 9:30 AM, DA 1 was observed removing resident trays, cups and bowls from

the dishwashing machine and storing them away to air dry. Food particles were observed stuck on trays and plastic cereal bowls. DA 1 was observed removing dishes from the dish machine with visible solid waste on it and returning them to the dishwasher (DW) to be washed again. Trays and bowls were observed washed and stacked to air dry. Food residue was observed on the trays and bowls. Tape was also observed stuck on trays that were stacked away to air dry. During the same observation of the dishwashing area, there were food particles, including small white grains covering the counter where the clean dishes were removed from

the dishwashing machine.

During a concurrent observation and interview with DA 1 and DS on 4/21/2025 at 9:40 AM, DA 1 confirmed by stating she removed dishes that were dirty and returned the dirty dishes to be washed. DA 1 stated she did not see the bowls and trays with food stains that were stored away to air dry. DA 1 stated the dirty dishes were contaminated and could cause problems in residents. The DS stated the tape on the trays should have been removed before washing. The DS then returned all the trays and cereal bowls to be rewashed. The DS confirmed by stating the clean counter next to the dishwashing machine was covered with food particles. The DS stated the food particles looked like cereal from the morning breakfast. The DS stated the cereal fell from

the dishes that were coming out of the dishwashing machine.

During a concurrent interview with the DS and the dishwasher (DW) on 4/21/2025 at 9:45 AM, the DW stated breakfast for 4/21/2025 was grits (a type of creamy hot cereal) and was stuck to the dishes. The DW confirmed the trays and cereal bowls were not clean. The DW stated he should have scraped and rinsed longer before loaded into the dishwasher. The DS then instructed the DW to scrape, rinse, and remove all

the visible soil from the dishes and then load them in the dish machine. The DS instructed the DW to remove

the tape from the trays and rewash all the trays and cereal bowls. The DS then instructed DA 1 and the DW to clean and sanitize the counters before rewashing the dishes.

A review of facility policy titled, Sanitization, revised 11/2022 indicated all utensils, counters, shelves and equipment were kept clean, maintained in good repair and were free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 055870 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 055870 B. Wing 04/24/2025

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

Sunray Healthcare Center 3210 W Pico Blvd Los Angeles, CA 90019

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 review of the 2022 U.S. Food and Drug Administration Food Code, Code 4-603.12 titled, Precleaning, indicated food debris on equipment and utensils shall be scraped over a waste disposal unit or garbage Level of Harm - Minimal harm or receptacle. If necessary for effective cleaning, utensils and equipment shall be pre flushed, presoaked, or potential for actual harm scrubbed with abrasives.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 055870