Sun Mar Nursing Center

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the necessary care and services. * The facility failed to ensure Resident 1 received adequate supervision to prevent an elopement (when a resident leaves a safe area without authorization). This failure had the potential to place the resident at risk for accident or injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan timely and implement care plan interventions for one of three sampled residents (Resident 1). * Resident 1 did not have a care plan for constipation. Additionally, Resident 1's care plan for diarrhea and loose stools was not developed in a timely manner. There was no monitoring for Resident1's signs and symptoms of dehydration as identified in the care plan. These failures had the potential risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the opened food items in the freezer were properly stored, dated, and labeled. * The facility failed to discard the items in the refrigerator that were past the use-by date, as per the facility's P&P. * The facility failed to ensure the juice boxes and thickener (for the juice dispenser) were properly labeled and discarded. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure the plastic cup was not stored inside the flour container. * The facility failed to air dry the kitchen equipment. [...]

Inspectors wrote2. On 6/11/25 at 0911 hours, Resident 1 was observed sitting on her wheelchair in the hallway outside her room. Resident 1 was observed with her right hand shaking. Medical record review for Resident 1 was initiated on 6/11/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's annual H&P examination dated 7/19/24, showed Resident 1's diagnoses included paranoid Schizophrenia, psychosis, dementia, and post status stroke with left side paralysis. Resident 1 had no capacity to understand and make medical decisions. Review of Resident 1's MAR for 6/2025 showed Resident 1 was being administered Abilify 15 mg, with a start date 9/15/21, at bedtime for schizophrenia manifested by episodes of delusional thinking that people were trying to harm her. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Residents 608) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 608. In addition, the facility failed to ensure the non-pharmacological interventions for Resident 608's pain was consistently documented prior to the administration of the Norco (narcotic pain medication) and failed to document the complete pain assessment for Resident 608's pain prior to the administration of pain medication as per Resident 608's care plan. These failures had the potential to put Resident 608 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wrote2. On 6/11/25 at 1116 hours, sn observation and concurrent interview was conducted with the DON. When asked about the facility's process for the disposition of controlled substances, the DON showed a drawer used to store the controlled substances to be destroyed with the pharmacist. According to the DON, the pharmacist and DON conducted disposition of the controlled substances on a monthly basis. During the observation of the drawer containing controlled substances for the disposal, one used patch without a pharmacy label was observed stored inside the drawer. The DON stated the patch was a Fentanyl (opioid) patch. When asked about the patch was missing a pharmacy label, the DON stated she knew who the patch was used for. On 6/13/25 at 1050 hours, a follow-up observation and concurrent interview was conducted with the DON. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review: * The facility failed to ensure the food item in the residents' refrigerator was properly labeled, dated, and discarded by the use-by date. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food brought in to the facility. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the arbitration agreement was explained in a form, manner, and language the residents or their representatives understood for two of three residents reviewed for the arbitration agreements (one nonsampled resident (Resident 23) and one final sampled resident (Resident 41). This failure posed the risk for the residents to not have a clear understanding of the arbitration process they signed.

Inspectors wroteBased on observation, interview, medical record reviews, facility document review, and facility P&P review , the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection surveillance program for January and February 2025. Specifically, the Infection Surveillance Monthly Report did not match the data recorded in the facility's Infection Control Summaries for those months. These failures posed a risk of unrecognized resident infections and increased the potential for transmission of communicable diseases throughout the facility.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to accurately assess the risk for falls for one of four final residents (Resident 30) reviewed for accidents. This failure had the potential to negatively impact Resident 30's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of five final sampled residents (Resident 22). * The facility failed to develop a care plan to address Resident 22's use of floor mat. This failure had the potential risk of not providing appropriate, consistent, and individualized care to Resident 22.

Inspectors wroteBased on observation and interview, the facility failed to maintain the essential equipment in a clean and safe operating condition when: * The washing machine detergent dispenser was not maintained in a clean/sanitary condition. This failure had the potential for the essential equipment to not function in the way it was intended and expose residents to unsafe practices.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure for a safe environment for one nonsampled Resident (Resident 1) as evidenced by: * Resident 1's room was observed with holes on ceiling and near the vent cover * The window screen inside Resident 1's bathroom was observed bent and not fully covering the window. These failures had the potential for pests to enter through these openings.

Inspectors wroteBased on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for 1 (Resident #30) of 2 sampled residents reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #30's Level I PASARR Screening reflected the presence of a serious diagnosed mental disorder.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of three sampled residents (Resident 1) was complete and accurately documented. * The SW failed to document the education provided to Resident 1's family member to explain long-term care benefits, including the share of cost. This failure had the potential for Resident 1 to not receive the accurate and appropriate care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the food was prepared and served in accordance with professional standards for food safety as evidence by:. * The facility failed to ensure the food which was prepared to be served to the residents from the kitchen was free from chemical contamination. * The facility failed to maintain the temperatures of the milk were appropriate when served to the residents. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was kept within reach for one of 18 final sampled residents (Resident 46). This failure had the potential for the resident to not be able to use the call light to summon assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the personal privacy for two of 18 final sampled residents (Residents 48 and 66) when: * Resident 48's curtain was not completely closed while the G tube medications were being administered. * Resident 66's room had a Hard of Hearing posting stapled above the head of bed. * Personal health information (PHI) on a computer terminal was left unattended with visible resident identifier information. These failures had the potential to negatively affect the dignity of the residents and violate privacy.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 50) received care in accordance with standards of practice. * Resident 50 received dialysis treatment (process of removing waste products and excess fluid from the body). The facility failed to place a dressing on Resident 50's tunneled dialysis catheter (a thin flexible hollow tube that is tunneled under the skin before entering a large vein) insertion site. This failure had to potential for Resident 50 to develop a central line-associated bloodstream infection (CLABSI, a serious infection that occurs when germs enter the bloodstream through the central line)

Inspectors wroteBased on observation and interview, the facility failed to ensure a stored medication bottle was properly labeled to include an expiration date. This failure had the potential for the residents at the facility to receive expired medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices to prevent the spread of infection as evidenced by: * The facility failed to follow the proper doffing practices before exiting a room on isolation precautions. * The facility failed to ensure the staff performed hand hygiene before and after contact in between residents. These failures had the potential for cross-contamination and spread of infectious organisms in the facility.