Sunnyview Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the information on the Minimum Data Set (MDS - a resident assessment tool) related to Health Conditions, was accurately documented to reflect Resident 1's fall on 1/16/2026. This failure had the potential to result in inaccurate facility quality measures and could result in Resident 1 not receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Safety and Supervision of Residents which indicated the facility would ensure interventions to reduce accident risks would be implemented for one of three sampled residents (Resident 1) by failing to provide one on one sitter (1:1- one staff delegated to supervise a single resident) for Resident 1 according to the residents care plan and Physician's Order. This failure resulted in Resident 1 sustaining an unwitnessed fall on 1/16/2026 and had the potential to cause injuries or hospitalization for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was notified of 1 of 8 sampled residents (Resident 1) pick-up time after hemodialysis treatment every Mondays, Wednesdays and Fridays. This failure resulted in Resident 1 having to wait for transportation for long periods of time after hemodialysis treatments. This failure also resulted in the hemodialysis center to utilize an Uber (a company that connects riders with drivers, couriers, and delivery providers through a smartphone app) transportation to take the resident back to the facility. This failure had the potential for Resident to experience being tired, uncomfortable, hungry and placed the resident's health and safety in jeopardy.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Skin Breakdown when licensed nurses did not perform weekly skin progress reports for one of four residents (Resident 1) who had moisture-associated skin damage (MASD - skin damage caused from prolonged exposure to moisture). This failure had the potential to result in the worsening of Resident 1's MASD and a delay in care or services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Bed-Holds and Returns when two of four sampled residents (Resident 1, 2) were not provided written notification of bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) upon admission or at transfer. This failure resulted in Resident 1 to not know their bed-hold rights during transfer to a general acute care hospital (GACH) and a potential for Resident 2 to not know their rights.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P/P) titled Care Plans, Comprehensive Person-Centered, 1. to conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) and 2. to document a post fall care plan for one of four sampled residents (Resident 2) after sliding out of the wheelchair and onto the floor. This failure resulted in Resident 2, who is non-verbal and bedbound, having another fall on 06/04/2025 of sliding out of the bed and onto the floor and staff returning Resident 2 to bed without informing the charge nurse or supervisor, and without having a qualified staff assess for injuries. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2), was assessed for pain after a fall incident on 6/5/2025. This failure resulted in the delay of pain assessment and interventions and had the potential for Resident 2 to suffer severe pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for three of 19 sampled residents (Residents 6, 72, and 10) by failing to: 1. Ensure Resident 6's risperidone (anti-psychotic medication used to treat several mental health conditions) was encoded as anti-psychotic medication (a type of drug used to treat symptoms of psychosis) under MDS section N (N0415 High Risk Drug Classes - Use and Indication). 2. Ensure Resident 72's significant weight loss (loss of 5 percent ([%] - out of each 100) or more in the last month or loss of 10% or more in last 6 months) was encoded under MDS Section K (K0300 Weight Loss). 3. Ensure Resident 10 had accurate documentation in the MDS to reflect her use of Dabigatran Etexilate Mesylate ([anti-coagulant]- medication used to thin the blood). [...]

Inspectors wrotesBased upon interview and record review, the facility failed to: 1. Ensure smoke break weren't limited for one of 5 sampled residents (Resident 55). This deficient practice resulted in violating Resident 55's rights to smoke.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and conduct an interdisciplinary team (([IDT] - team members from different disciplines who come together to discuss resident care) meeting before initiation of a psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for resident with diagnosis of dementia (a progressive state of decline in mental abilities) for one of six sampled residents (Resident 35). This deficient practice had the potential for Resident 35 to receive unnecessary medications.

Inspectors wroteBased upon observation and interview, the facility failed to: 1. Ensure the room's curtains and curtain rod was not broken for one of 5 sampled residents (Resident 79). This deficient practice resulted in a violation of Resident 79's right to privacy and a potential to result in a safety hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to prevent a decline in joint range of motion ([ROM] - full movement potential of a joint) for two out of two sampled residents (Resident 24 and 76) who had limited ROM by failing to: 1. Ensure 24 received timely quarterly (every three months) Joint Mobility Screening/Assessment to monitor changes in joint range of motion. 2. Ensure one of seven sampled residents (Resident 76) received passive range of motion ([PROM]- movement of a joint through its full range of motion without any effort from the individual) exercises seven days a week by the Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV] - a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) was removed after IV antibiotic (a drug used to treat infections caused by bacteria) was completed for one of one sampled resident (Resident 57). This deficient practice had the potential for the IV insertion site to develop infection and/or hospitalization for Resident 57.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure accurate accounting/documentation of a controlled drug ([Lyrica]- medication used for nerve pain) for one out of seven sampled residents (Resident 21). This deficient practice had the potential to result in drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to consider ordering valproic acid level (test that measures the concentration of valproic acid, an anticonvulsant medication, in the blood) and ammonia level (test that measures the amount of ammonia level in the blood) was acknowledged and acted upon for one of five sampled residents (Resident 72). This deficient practice had the potential for Resident 72 to experience a delay in treatment.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) to check ammonia level (test that measures the amount of ammonia level in the blood) was completed monthly as ordered by the physician for one of 19 sampled residents (Resident 24). This deficient practice had the potential for Resident 24 not receiving necessary medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 31) had enhanced barrier precautions ([EBP]- infection control strategy aimed at reducing the transmission of bacteria resistant to antibiotics) was implemented when care was provided to his feeding tube (a flexible plastic tube placed into the stomach to help you get nutrition when you're unable to eat). This deficient practice put Resident 31 at risk for infection.

Inspectors wroteBased upon observation and interview, the facility failed to: 1. Ensure 1 of 2 trash dumpster lids were closed. This deficient practice had the potential to result in unwanted pests and vermin.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its policy and procedure (P&P) titled, Identifying Abuse which indicated the facility did not condone any form of resident abuse or neglect for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 2 physically assaulting Resident 1, causing serious injuries such as a swelling to the right side of Resident 1's forehead, and a zygomatic arch fracture (a break in the cheekbone).

Inspectors wroteBased on interview and record review, the facility failed to implement 1 of 3 sampled residents ' , (Resident 1) care plan titled, Resident non-compliant manifested by refusing medications, history of refusing to take medications for 2 months, which indicated to hold an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) to address non-compliant behavior. This failure resulted in Resident 1 ' s continued refusal of medications not addressed, and had the potential to affect in maintaining the resident ' s highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Work Practices, which indicated drinks should not be stored in areas of possible contamination. This failure had the potential to cause cross contamination. wellness.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) had a care plan for Activities of Daily Living (ADL- routine tasks/activities such as bathing, dressing, and toileting a person of life-threatening conditions) specific to showering with interventions. These deficient practice had the potential for the resident to not receive care services specific to resident's needs which can result in Resident 1 sustaining another fall.

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of two of four sampled Resident ' s (Resident 1 and Resident 4) by failing to: 1. Ensure Resident 1 ' s ID (identification) card, Medi-Cal card and passport were documented on the resident ' s Inventory List. 2. Ensure Resident 3 ' s Compact Discs (CDs) was not lost or stolen. This deficient practice had the potential for Resident 1 ' s personal belongings to be lost or stolen without accountability and could negatively affect Resident 3 ' s psychosocial well-being.

Inspectors wroteBased on interview and record review, for one of three residents ' (Resident 1), the facility failed to: 1. Ensure Resident 1 had an order for oxygen administration. 2. Call the physician for Resident 1, who received oxygen without a physician ' s order and suffered a low oxygen saturation (O2 Sat- [%] measures how much oxygen is in the blood, normal range 95% to 100%) of 79%-81% on 10/2/2024. 3. Provide the treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This failure resulted in the resident ' s delay in receiving interventions from the physician which could have prevented resident ' s transfer to the general acute care hospital (GACH).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for one out of three sampled residents (Resident 1). This failure resulted in incomplete resident records necessary in providing care to Resident 1.

Inspectors wroteBased on observation and interview the facility failed to ensure call lights were placed within reach for three of 19 sampled residents (Resident 43, 65, and 72). This deficient practice had the potential to result in a delay in or inability for the residents to obtain necessary care and services in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks were performed yearly for three of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. A received-by and delivery dates were placed on 3 tubs of frozen ice cream in freezer # 5. 2. Dirty aprons were not placed in the dry storage area of the kitchen. This deficient practice had the potential to result in foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement infection control measures for two of two sampled residents (Residents 15 and 24) by failing to wear Personal Protective Equipment ([PPE] gown - specialized clothing or equipment worn by an employee for protection against infectious materials) prior to entering and administering medication via g-tube to Resident 15 and Resident 24 on Enhanced Standard Precautions ([ESP] a resident-centered and activity-based approach for preventing Multiple Drug Resistant Organism ([MDRO]-are bacteria that have become resistant to certain antibiotics) transmission in skilled nursing facilities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents who had physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) were evaluated regularly and less restrictive measures were attempted for one of one sampled resident (Resident 69). This deficient practice had the potential to place Resident 69 at risk for unnecessary prolonged use of restraint that could lead to decline in physical functioning and not being treated with respect and dignity.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of eight sampled residents (Resident 2), Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability [a term used when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills], or related condition) level one (I) screening was re-submitted after a hospital exemption and Resident 2 had stayed in the facility for more than 30 days the appropriate state-designated authority for a PASRR level two (II) evaluation and determination. This deficient practice had the potential for Resident 2 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Fill out the Preadmission Screening and Resident Review ([PASRR], a tool to determine if the person had, or was suspected of having, a mental illness, intellectual disability, or related condition) level one screening and refer one of eight sampled residents (Resident 15) who had a diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behave) to the appropriate state-designated authority for PASRR level two evaluation and determination. This deficient practice had the potential to result in Resident 15 not receiving appropriate treatment recommendations for schizophrenia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement care plan intervention of placing a bed alarm while in bed for one of three sampled residents (Resident 69) who was identified at risk for fall. This failure had the potential to cause further fall for Resident 69.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure: 1. A nasal cannula for oxygen use was dated and properly stored to prevent contamination for one out of 5 residents (Resident 41). This deficient practice had the potential to result in complications associated with oxygen therapy, negatively impacting the health and well-being of the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Document one of one sampled resident (Resident 65)'s refusing splints (an external device used to support and immobilize an injury or joint) on the left hand and left knee. This failure had the potential to result in Resident 65's existing contractures (tightening of the muscles and tendons that causes the joints to shorten and become very stiff) to worsen.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the status of three of 23 sampled residents (Resident 32, 43, and 63), Pre-admission Screening and Resident Review (PASRR) Level II and integrate the level of care into a plan of care. The deficient practice had the potential to result in Resident 32, 43 and 63 not receiving the appropriate care and management for their mental illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on a comprehensive assessment, that Resident 68 did not receive Lamictal (a mood stabilizer medication that works in the brain) and Risperdal (an antipsychotic medication used to treat mental illness), a psychotropics (medications capable of affecting the mind, emotions, and behavior) unless it was necessary to treat a specific condition. The facility also failed to perform a gradual dose reduction and implement behavioral interventions, to discontinue the psychotropic drug. As a result, Resident 68 was placed at unnecessary risk of unwanted and irreversible side effects and adverse drug reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater as evidenced by six medication errors out of 25 opportunities for error to yield a medication error rate of 24 %, for three of five residents (Residents 14, Resident 15, and Resident 80) observed during medication administration (med pass). a. The facility failed to administer Resident 14's prescribed over the counter (OTC) house supply medication docusate sodium (used to treat constipation) and MiraLAX (used to treat occasional constipation) as ordered by the physician. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on renal diet (type of diet prescribed for patients with kidney disease) with and soft, bite size texture were served the diet according to the menu and spreadsheet instructions (food portioning and serving guide). This deficient practice had the potential to result in increase in potassium (a chemical that is critical to the function of nerve and muscle cells, including those in your heart) levels, meal dissatisfaction and decreased food intake in 3 of 6 residents who were on renal diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage in the kitchen when: 1. Four pieces sliced ready to eat ham were stored in the reach in refrigerator with date of 2/28/22 and a medium size plastic container of sliced ham was stored in reach in refrigerator with date of 3/2/22 exceeding storage period of ready to eat lunch meat. Fully cooked half of a ham was thawing in the reach in refrigerator with no thaw date. 2. A large bag of expired frozen cookie dough was stored in the facility reach in freezer. These failures 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 77 out of 83 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of infection in accordance with its infection prevention and control program for three of 83 sampled residents (Residents 22, 81, 10, and 70) by failing to ensure: 1. Restorative Nurse Assistant (RNA) 2 performed hand hygiene before, after and between providing care for Resident 22 and 81. 2. Certified Nurse Assistant (CNA) 3 performed hand hygiene before, after and between providing care for Resident 10 and 70. This deficient practice had the potential to lead to the spread of infection among residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of one sample resident (Resident 36's) privacy and dignity by failing to provide a privacy bag (a pouch that conceals a urinary drainage bag [bag that collects urine] from public view). This deficient practice had the potential to affect Resident 36's self-esteem and self-worth. During a review of Resident 36's admission Record (facesheet), the face sheet indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36' s diagnoses included diabetes mellitus type 2 (abnormal blood sugar), chronic kidney disease (when the kidneys no longer work as they should to meet the body's needs) and blindness (unable to see). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to involve the Responsible party ([RP] person who makes medical decisions for a resident, who is not able to make decisions for themselves) for one of 23 sampled residents (Resident 39), in the care planning process. This deficient practice had the potential to violate Resident 39 RP's right to be an active participant in Resident 39's care. During a review of Resident 39's admission Record (facesheet), the face sheet indicated Resident 39 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination for one resident out of 23 sampled residents (Resident 46), by not allowing resident 46 to exercise her choice of when to take a shower. This deficient practice had the potential to cause a negative impact on the psychosocial well-being of Resident 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan addressing the diagnosis of major depressive disorder (a mental health disorder characterized by a persistent sad mood or loss of interest in activities, causing significant impairment in daily life) for three of 23 sampled residents (Residents 57, 47, and 68). This deficient practice had the potential for the residents not to receive individualized care and treatment to meet their psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive and resident-centered care plans, for three of 23 sample residents (Resident 5,36, 83) by failing to: 1) Implement Resident 5's care plan causing a three-month delay in physical therapy (PT) and occupational therapy (OT). 2) Implement Resident 36's care interventions to monitor for signs and symptoms of urinary tract infection (UTI-infection affecting the organs [kidneys, bladder, urethra] of the urinary system) for a resident with an indwelling urinary catheter (a tube inserted into the body to empty urine from the bladder into a bag outside the body). 3) Develop a fall care plan for Resident 83, who was at high risk for falls. These deficient practices have the potential to negatively the health and the delivery of care and services to Residents 5, 36, 83. A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and maintain an indwelling urinary catheter (a tube inserted into the body to empty urine from the bladder into a bag outside the body) for one of one sample residents (Resident 36). This deficient practice had the potential to negatively affect Resident 36's plan of care and increase the risk of a urinary tract infection ([UTI] an infection affecting the urinary system including). During a review of Resident 36's admission Record (facesheet), the face sheet indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure two of 23 residents (Resident 21 and 47) received treatment and care in accordance with professional standards of practice by failing to ensure: 1. Resident 21 had ordered labs drawn for a Hemoglobin A1c ([HgA1c] diagnostic blood test that measures the average blood sugar levels over the past three months) and Digoxin level. (Medication that treats heart failure and heart rhythm problems). 2. Resident 47 was provided proper repositioning care. These deficient practices had the potential to lead to an increased risk of hyperglycemia (high blood sugar), risk of infection, delayed wound healing, hospitalizations, diabetic coma, and death for Resident 21 and had the potential to negatively affect Residents 47's physical comfort, skin integrity, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 5), with limited range of motion (ROM - the extent of movement of a joint) received the appropriate treatment and services to maintain ROM by failing to: 1. Implement Resident 5's care plan to provide Rehab as ordered by the physician causing a three-month delay in physical therapy (PT) and occupational therapy (OT). 2. Ensure PT and OT services were provided as ordered by the physician. This deficient practice had the potential to place Resident 5 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a review of Resident 5's admission record (facesheet), the face sheet indicated Resident 5 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided to one of 23 sampled residents (Resident 68). This deficient practice had the potential to prevent Resident 68 from attaining or maintaining her highest practicable level of well- being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a licensed nurse did not crush seven (7) medications together and administer them to one of five sampled residents (Resident 14) observed. (Cross Reference F759) This deficient practice had the potential to cause harm to the resident due to receiving a medication combination not ordered by the physician.

Inspectors wroteBased on observation and interview the facility failed to: 1. Store medication at the correct temperature as required by the manufacturer's specifications for one of two medication carts (Station 2 Medication Cart 2) observed. 2. Ensure expired and discontinued medications was destroyed in accordance with the facility's policy titled, Medication Destruction. These deficient practices had the potential to negatively affect the residents' health and well-being by improperly storing medications that required refrigeration and failure to destroy expired and discontinued medications remaining in the facility for over 90 days.