Sunland Post Acute

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

should have been conducted with Resident 4 following her refusal of facility medications to understand why Resident 4 was not taking her medication. The DON stated that an IDT should be conducted prior to any resident self-administering medications and the physician should have been contacted to discuss Resident 4's medications and obtain a physician order for self-administration of medications.During a review of the facility's policy and procedure (P&P) titled, Medication-Self Administration, dated 5/14/2025, the policy indicated it is the policy of the facility that residents have the right to self-administer medications if the interdisciplinary team determines that this practice is clinically appropriate. On admission or shortly thereafter, each resident will be assessed to determine if they want to self-administer their medications. It is

the responsibility of the IDT to determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. The IDT must determine where the resident or the nursing staff will be responsible for storge and documentation of the administration of the medications, as well as, the location where the medications will be administered. These determinations should appear on the resident's comprehensive plan of care. The residents will be assessed quarterly to determine their ability to continue to self-administer their medications. The determination of whether it is safe for the resident to self-administer medications should be completed within seven days of the completion of the resident's comprehensive assessment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunland Post Acute

8647 Fenwick Street.

Sunland, CA 91040

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of five sampled residents (Resident 5) addressing Resident 5's behavior of spitting.This deficient practice had the potential to result in failure to deliver the necessary care and services.? Findings:During a

review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident

on 3/28/2020 with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (a condition characterized by high levels of fats in the blood), dementia (a progress state of decline in mental status), and dysphagia (difficulty swallowing).During a review of Resident 5's History and Physical (H&P) dated 3/4/2025, the H&P indicated Resident 5 does not have the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 6/12/2025, the MDS indicated Resident 5's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated Resident 5 requires set up assist with eating, maximal assistance with oral hygiene, toileting, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 5 is dependent on staff for showering.During an interview on 9/11/2025 at 1:00 p.m., with Certified Nursing Attendant 1 (CNA 1), CNA 1 stated that Resident 5 has a long history of spitting and will provide her (Resident 5) with a small trash located next to her bed or place the small trash can by her wheelchair when she is out of bed. CNA 1 stated that she (CNA 1) will remind Resident 5 to spit into the trash can instead of the floor.During a concurrent interview and record review on 9/11/2025 at 4:00 p.m., with the Director of Nursing (DON), reviewed Resident 5's care plans. The DON stated that she (DON) was unaware of Resident 5 having episodes of spitting. The DON confirmed by stating that Resident 5 should have a care plan in place to address Resident 5's episodes of spitting. The DON stated that she has directed staff to provide Resident 5 with a basin to use during the episodes of spitting.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Planning, dated 5/14/2025, the policy indicated it is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan will provide specific information to include resident strengths, goals, left history and preferences discharge planning and will be completed withing seven days of care area assessment completion. Based upon the resident assessment the care plan may include addressing oral care, skin integrity, medical treatment/diagnostic testing based on the resident's choices/directives, symptom management, nutrition and hydration and activities/psychosocial needs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunland Post Acute

8647 Fenwick Street.

Sunland, CA 91040

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 Level of Harm - Minimal harm or potential for actual harm

duration record (MAR):1. Date and time of administration.2. Amount administered.3. Signature of the nurse administering the dose on the accountability record at the time the administration is removed from the supply.4. Initials to the nurse administering the dose on the MAR after the medication is administered.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunland Post Acute

8647 Fenwick Street.

Sunland, CA 91040

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

drug or other substance that affects mood or behavior) is discontinued, licensed nurses are to bring the narcotic medication and the Individual Count Sheet Record to the DON. The DON continued to state that once she (DON) received the narcotic medication and Individual Count Sheet Record, she then locks the narcotic medication and Individual Count Sheet Record in a cabinet for safe keeping. The DON stated that

the pharmacist comes to the facility monthly and will then destroy narcotic medications together with the DON to be each other's witness. The DON stated that she reviewed her medication destruction log and lorazepam oral concentrate 2mg/mL RX# 4005429 dated 8/1/2025 was not given to her for safe keeping and has not been destroyed. During a follow-up interview on 9/11/2025 at 11:23 a.m., with the DON, the DON stated that the bottle of lorazepam oral concentrate 2mg/mL with the RX# 4005429 dated 8/1/2025 is gone and was not located. The DON further stated that the facility failed to ensure that a bottle of lorazepam was kept safe. The DON stated that licensed nurses should have done their job by making sure

they are giving the correct endorsements and taking accountability of controlled medications upon shift change.During a review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines: Controlled Medications, review date 5/14/2025, the policy indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (medications that are considered to have a strong potential for abuse) are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state law regulations. The Director of Nursing and the consultant pharmacist maintain the facility's compliance with federal and state law and regulations

in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container

it must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. The same process applies to

the disposal of unusual partial tablets and unused portions of single dose ampules (small, usually glass, container of a single measured amount of medicine).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunland Post Acute

8647 Fenwick Street.

Sunland, CA 91040

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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Profile dated 4/29/2025, the Dietary Profile indicated Resident 7 dislikes rice.During a concurrent interview and record review on 9/11/2025 at 1:56 p.m., with the DDS, reviewed Resident 7's Dietary Profile dated 4/29/2025. The DDS stated that residents' preferences are updated quarterly and as needed and documented on residents' dietary profile. The DDS stated that the DDS missed the last quarterly update for Resident 7's Dietary Profile, which should have been updated in July 2025. The DDS stated that he (DDS) should have updated and documented Resident 7's dislikes in Resident 7's chart. The DDS stated that he failed to update Resident 7's Dietary Profile dislikes and stated that it is important to update residents' dietary profile because it is their right to choose what they want to eat and what should be served during meals. During a review of the facility's policy and procedure (P&P) titled, Food Preferences, last reviewed 5/14/2925, the policy indicated resident's food preferences will be adhered to within reason. Food preferences will be obtained as soon as possible through the initial resident screen. This screening must be completed within seven days of admission by the FNS director. Food preferences can be obtained from the resident family for staff members. Updating of food preferences will be done as the resident's needs change and/or during the quarterly review.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunland Post Acute

8647 Fenwick Street.

Sunland, CA 91040

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure clear storage cups of gelatin were dated and labeled according to the facility's policy.This deficient practice had the potential to place 109 out of 116 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).Findings:During an observation of the facility's kitchen refrigerator on 9/11/2025 at 11:55 a.m., observed open food items not in its original packaging and placed in clear storage cups not labeled.During a concurrent observation and interview on 9/11/2025 at 11:56 p.m., with the Dietary Aide (DA), the DA stated that the clear storage cups are cups of gelatine for the residents. Observed the DA count the clear storage cups. The DA stated 11 of the clear storage cups had no label. The DA stated that

the gelatin in clear storage cups were sugar free gelatin for residents who are diabetic. During an interview

on 9/11/2025 at 11:57 p.m., with the Director of Dietary Services (DDS), the DDS stated that clear storage cups were sugar free gelatin and should be labeled SF to mean sugar free. The DDS stated that when a food item is not in its original packaging, the food item must be labeled with the name or description of the food item and the date when the food item was opened/prepared. When asked about the importance of accurate labeling, the DDS stated that it is important to label food items to make sure that the food item is what it is and for the safety of the residents.During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, last reviewed 5/14/2025, the policy indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. All prepared foods need to be covered, labeled and dated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunland Post Acute

8647 Fenwick Street.

Sunland, CA 91040

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 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 3) had a functioning call light (a device used by a resident to signal his/her need for assistance from staff). This deficient practice had the potential to result in a delay in meeting the residents' needs for assistance which could have left the resident feeling isolated and at an increased risk for falls or accidents.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 9/2/2025 with diagnoses that included hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) following cerebral infarction (stroke- loss of blood flow to a part of the brain) affecting right dominant side, history of falling, and difficulty swallowing.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 9/2/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired.During a review of Resident 3's History and Physical (H&P) dated 9/5/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions.During an observation on 9/10/2025 at 9:30 a.m., a test was conducted of Resident 3's call light and was found to be not operating.During a concurrent observation and interview on 9/10/2025 at 9:31 a.m., with Registered Nurse Supervisor 1 (RNS 1), observed Resident 3's call light. RNS 1 confirmed by stating that Resident 3's call light was not working and RNS 1 noted that it had to be plugged in to be operating properly. RNS 1 tested call light after plugging the call light in and the call light was found to be operating properly.During an interview on 9/11/2025 at 4:00 p.m., with the Director of Nursing (DON), the DON stated that all residents should have a functioning call light to alert staff of any needs that they have. The DON stated that Resident 3 had the potential to have a delay in the care provided, increased risk for falls or accidents, and decreased quality of care.During a review of the facility's policy and procedure (P&P) titled, Call Lights, dated 5/14/2025, the P&P indicated it is the policy of the facility to respond to the resident's requests and needs. A newly admitted resident should be shown the call light in the room and in the restroom and how to operate them. The residents should do a return demonstration so that the facility can be sure that the resident can operate the call light. When the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within easy reach of the resident and can operate the call light.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet