Sunny View Manor

Inspectors wroteBased on observation, dietary staff interview and document review, the facility failed to conserve nutritional food value. The cooked food prepared for lunch on 4/14/25 were placed on the steamtable 1 1/2 hours prior to service. This failure had the potential to compromise nutritional quality and palatability of residents who received meals from the kitchen.

Inspectors wroteBased on observation, dietary staff interview and document review, the facility failed to ensure staff competency when two of two kitchen staff did not follow manufacturer's instruction when testing the potency of a chemical used to sanitize kitchen cookware. This failure had the potential of cookware not being sanitized and placed residents at health risk.

Inspectors wroteBased on observation, dietary staff interview and document review the facility failed to ensure cooked foods were stored under safe temperatures and failed to cover meats and vegetables in the walk-in refrigerator. The failure of not verifying meat temperatures after blast chilling (rapidly chilling food with cold air) had the potential of causing food borne illness had the foods were not chilled to the correct temperature. The failure of not covering refrigerated foods had the potential to diminish its taste and placed the risk for food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for administering oxygen (colorless and odorless gas which is essential for life) for one of two residents (Resident 83). This failure had the potential to compromise Resident 83's well- being.

Inspectors wroteBased on interview and record review, The facility failed to ensure staff promptly reported a significant change in condition to the physician for one of two sampled residents (Resident 1). Staff failed to promptly report a significant change in condition to the physician when Resident 1 showed a reduced level of alertness and Resident 1's Glasgow Coma Scale (a scale used to reliably measure a person's level of consciousness after a brain injury) was 9 out of 15 (where a score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate brain injury, and a score of 8 or less represents severe brain injury). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage and preparation in the kitchen when: 1. Produce was not labeled or dated in the walk-in refrigerator. 2. Hot foods were not kept at 135 degrees Fahrenheit during meal service tray line. These failures had the potential for all residents in the facility to be introduced to food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified Nursing Assistant F (CNA F) did not perform hand hygiene in between Resident 83's bed making task and glove changed; 2. Certified Nursing Assistant G (CNA G) did not perform hand hygiene in between serving food to residents (Residents 15, 184, 16 and 8) and when assisting two residents with meals (Residents 5 and 83); and 3. Registered Nurse C (RN C) did not perform hand hygiene in between medication administration task and glove changed (Residents 134 and 233). These failures had the potential to compromise resident's health and safety in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan when one of 12 sampled residents (Resident 233) did not have application of left-arm brace included in the Care Plan (CP). This failure had the potential to result in inadequate communication between staff in providing necessary treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided to meet the professional standards of practice for one of five sampled residents (Residents 233) when registered nurse C (RN C ) did not shake the Med Plus (nutritional supplement) as directed prior to pouring in the medication cup; the Med Plus was not dated when opened; and RN C provided a wrong consistency of Med Plus to Resident 233, nectar thick consistency (liquids that are easily pourable and are comparable to heavy syrup found in canned fruit) instead of thin liquids as diet ordered. These failures had the potential to jeopardize the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for effective communication when a facility did not provide language assistance or other communication aid to two of three sampled residents with language barrier (speaking in foreign language) (Residents 83 and 4). This failure had the potential to affect the psychosocial well-being of these residents and a decline in their activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 16) remained free from accident hazards due to the use of bed rail (side rail) when Resident 16 had the left upper bed rail raised up while in bed without bed rail assessment, physician's order and care plan. This failure had the potential to put Resident 16 at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe administration of medication and accurate accountability of controlled medications (those with high potential for abuse or addiction) when: 1. Registered nurse E (RN E) left the medication at resident's overbed table without ensuring Resident 136 had swallowed the solution. This failure had the potential for resident not taking the medications or having swallowing difficulty or choking without the nurse present for immediate help; and 2. Random controlled medication use audits for 2 out of 5 residents (Residents 135 and 8) did not reconcile. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all drugs and biologicals (therapeutic substance like a vaccine or drug) are labeled in accordance with professional standards, when expired Prostat (liquid protein supplement) bottles were found in the medication storage room. This failure could potentially compromise the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the correct therapeutic diet (A therapeutic diet is a meal plan that controls the intake of certain foods and food consistency) to one of 41 sampled residents (Resident 4) as ordered by Resident 4's physician. This failure had the potential for Resident 4 to choke on foods not prepared in the correct consistency.

Inspectors wroteBased of observation, interview, and facility document review, the facility failed to ensure the registered dietitian effectively carried out the functions of the Food and Nutrition Services as evidenced by lapses in the delivery of services associated with staff competency (Cross-reference F802), portion sizes for puree diets (cross-reference F803), food safety and sanitation (Cross-reference F812), and pests in the kitchen (Cross-reference F925). This failure to ensure food and nutrition services systems are accurately and effectively delivered may result in food borne illness for a highly susceptible population and/or not meeting the nutritional needs of the 31 residents who ate food by mouth from the kitchen out of a facility census of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe sanitary practice in the kitchen. The facility failed to ensure food was stored and prepared under sanitary conditions when: 1. Time temperature control for safety foods (TCS - another name for Potentially Hazardous food)) that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were not properly cooled down, 2. Cups for fruit, and mugs for juice were stored with residue inside; 3. The meat slicer was stored with food particles on it; 4. The can opener had residue build-up around the blade and base; 5. No use by dates labeled on the eight pieces of vacuumized flat iron steak inside the walk -in refrigerator and thawing meat had no dates to indicate when it was put in the refrigerator; and 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when one staff did not properly prepare pureed foods (a texture modified diet that minimizes the amount of chewing required and increases the ease of swallowing). This failure had the potential to decrease the attractiveness, flavor, and nutrients, possibly resulting in decreased dietary intake and may result in not meeting the nutrition needs for six residents receiving puree foods out of a facility census of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident group agreed to a meal span of more than 14 hours between a substantial evening meal and breakfast the following day. This failure had the potential to not meet the needs of 31 residents eating meals at the facility out of a census of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper disposal of garbage in the dumpster container when it was not properly contained, overflowing, and left open. This failure had the potential for a hazardous environment for the residents and staff due to possible harborage and feeding of pest.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective infection control process when: 1. An incentive spirometer's (I.S. medical device to improve lung function) hose was touching the table surface; 2. A dirty oxygen concentrator (medical device for oxygen therapy) was stored in the clean utility room; 3. Used hand sanitizing wipes were left on the dining table accessible to resident; 4. An opened dirty laundry bag was exposed on top of a dirty linen cart; 5. A nasal cannula tubing (device used to deliver oxygen to a person) did not have a date of placement and monitoring sheet; 6. Licensed Vocational Nurse F (LVN F) did not wash her hands before administering the eye drop to Resident 231, and LVN F did not wash or sanitize her hands after administering medication to Resident 231; 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was free of pests as evidenced by flying insects seen near the kitchen drains and ant on the kitchen wall near the freezer. This failure to maintain an effective pest control program had the potential to cause a health hazard to the residents and staff eating food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and respect for one of twelve sampled residents (Resident 2) when staff did not assist Resident 2 during lunch while another resident at the same table was already eating with staff assistance. This deficient practice violated the resident's right to be treated with dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safety when Resident 24 administered his own medication and it was not stored properly for one of twelve sampled residents (Resident 24). This failure had the potential to results in improper use of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure contact information of the California Department of Public Health District Office (CDPH DO) was accessible for four of four residents (Residents 4, 15, 16, and 20). This failure had the potential for residents not to file for complaints and grievances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for three of 12 residents (12, 14 and 16) when: 1. Resident 12 had an arteriovenous (AV) shunt (a connection made between an artery and a vein) for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on her left upper arm. Certified nursing assistant D (CNA D) stated he took Resident 12's blood pressure on her left wrist; 2. Restorative nursing assistant (RNA) program was not followed for Resident 12 to provide two times per week instead of three times per week. Resident 16's RNA program three times per week instead of five times per week as ordered by the physician; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 12 percent (% unit of measurement) error rate when three medication errors out of 25 opportunities were observed during a medication pass for three of 11 residents (9, 17, and 231). These failures resulted in medications not given in accordance with prescriber's orders, which had the potential for residents to not receiving the full therapeutic effect of the medications or had the potential for preventable side effects for the residents.

Inspectors wroteBased on observation, staff interview, and facilty record review, the facility failed to ensure the planned menu was followed when two out of two residents (Residents # 20, 22) on regular pureed diets (texture modified diets for people with chewing or swallowing difficulties) were served the wrong portion size for the entrée. This failure had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of these residents, out of a facility census of 32.