Sunrise Post Acute

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of physical abuse was reported to the State agency immediately, but not later than two hours after the allegation was made, for one of two residents reviewed for abuse (Resident 1). This failure had the potential to delay investigation of the allegation and implementation of measures necessary to ensure resident safety and prevent further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavioral symptoms for one of two residents reviewed (Resident 1). This failure had the potential to result in staff lacking appropriate guidance and interventions to consistently address the resident's behavioral symptoms and monitor the effectiveness of interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated annually and as needed. This failure resulted in an inaccurate evaluation of the facility's population and resources needed to provide the necessary care and services for the residents.

Inspectors wroteBased on interview and record review, the facility Quality Assurance and Performance Improvement Program (QAPI) failed to identify and address their deficient practice involving physician visits (cross reference F0712). This failure has the potential to put residents at risk for unidentified medical conditions which could result in inadequate quality of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the fluid intake and output in 24 hours was accurately monitored, recorded, and evaluated as ordered by the physician for one of one resident reviewed (Resident 19). This failure had the potential for the resident to experience complications associated with fluid deficit and/or fluid overload.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician conducted the initial visit for five of ten sampled residents (Residents 28, 35, 26, 22, 47). These failures had the potential to result in unidentified medical conditions and/or insufficient provision of medical treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' right to self-administer medications for one of two residents (Resident 26) reviewed, when one opened box of Systane (eyedrops to prevent dryness of the eyes), a box of Lmnoop eczema relief cream (eczema-skin condition causing itching and dryness), and a bottle of Migrastil pain roll-on (pain relief cream) were observed on top of the resident's bedside table. This failure had the potential for Resident 26 to self-administer medications without a physician's order.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 6) was free from unnecessary medications when adequate indications (clinical rationale) for antipsychotic (drug to reduce disordered thinking) use were not documented. This failure had the potential for the resident to experience adverse outcomes from the unnecessary use of the antipsychotic medication such as Neuroleptic Malignant Syndrome (life-threatening reaction), tardive dyskinesia (chronic, involuntary movements), and increased risk of falls that could impair their ability to function at their highest level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, a left elbow skin discoloration, identified on September 9, 2025, was reported and referred to the physician in a timely manner for treatment orders, for one of eight resident's reviewed (Resident 8). This failure has the potential for the resident to experience complications due to the delay in monitoring and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident reviewed for oxygen administration (Resident 4), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, an assessment was conducted by Licensed Vocational Nurse (LVN) 1, prior to obtaining a pain medication order to treat migraine ( severe headache) for one of eight residents reviewed (Resident 35). This failure has the potential to result to inadequate pain management for Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when: 1. For two of two residents (Resident 34 and Resident 35), inhalers were not appropriately administered. This failure had the potential for the residents to experience preventable breathing problems and/or other adverse clinical outcomes. 2. One of one opened blood glucose (sugar) test strip vial stored in the medication cart was undated in accordance with the manufacturer's instructions. This failure had the potential for unusable test strips to be used to measure residents' fingerstick blood glucose levels to determine the dose of insulin to be administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective medication labeling and controlled (narcotics) drug storage when: 1. Three of three artificial tears (drug to lubricate dry eyes) medication bottles were not properly labeled with sufficient information to identify the specific resident. This failure had to potential to cause preventable infections from cross-contamination from eye drops were inadvertently mixed up with other residents. 2. The keys to the discontinued controlled substances were stored in an unlocked drawer in the half-opened Director of Nursing (DON) office. This failure had the potential for drug diversion (theft or preventable loss) and impaired (under the influence) staff providing care for a universe of 62 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nutrition services were provided for two of three residents (Resident 22 and Resident 26) reviewed, when:1. Resident 22, dietary preferences were not met; and2. Resident 26 annual (yearly) nutritional assessment had not been conducted. These failures had the potential for Resident 22 and Resident 26 to have inadequate dietary intake because reasonable efforts were not made to accommodate Resident 22's food preferences and Resident 26's annual nutritional assessment were not performed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to a vulnerable facility population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were followed and implemented when two employees from a consulting doctor's office did not follow an Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that required use of gown and glove during high contact resident care activities) for one of five residents reviewed (Resident 59). This failure had the potential to increase the spread of pathogens (germs) and infections by staff to the residents.

Inspectors wroteBased on interview and record review, the facility failed for one of two sampled residents (Resident 2), to protect the resident ' s rights to be free from physical abuse by a resident, when a resident (Resident 1), diagnosed with dementia, and anxiety with no identified behavioral triggers, was moved rooms multiple times due to intolerance to noise without assessing the resident ' s individual needs. The failure of the facility in assessing resident ' s need for appropriate room placement resulted in Resident 1 assaulting Resident 2 who exhibited frequent moaning, mumbling, and yelling. Resident 2 sustained lacerations (a cut in the skin) to the head, extensive facial fractures (a break in a bone), two right rib fractures and L1 vertebra fracture (a break on the first bone on the lower back) and later passed away in the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan (a document that outlines a patient's current health status, diagnoses, treatment goals, and interventions) to address the potential risk for physical agression related to the resident's preference for a quiet environment for one of two sampled residents (Resident 1). This failure resulted in Resident 1 being placed in a room with a resident (Resident 2), who exhibits behaviors of moaning and yelling, which subsequently resulted in Resident 1 assaulting Resident 2, with Resident 2 sustaining lacerations, extensive facial fractures, rib fractures and vertebra fracture. Resident 2 was transferred to the general acute care hospital (GACH), where the resident expired.

Inspectors wroteBased on interview and record review, the facility failed to ensure a report with sufficient information to describe the alleged physical abuse that occurred between two residents (Residents 1 and 2) was provided to the State Agency (SA) and Long Term Care (LTC) Ombudsman (a resident advocate) on May 8, 2025. This failure had the potential for the SA and other officials to receive misleading informations which could negatively affect the investigation compromising the safety of the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of three residents (Resident 1), to ensure an Advance Directive Acknowledgement (AD- written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself), Consent to Treat, POLST (Physician Orders for Life Sustaining Treatment - a physician's order that outlines a plan for end of life care reflecting both a resident's preference and a physician's judgement based on medical evaluation), and Bed Hold Notification Policy were initiated and/or discussed with the resident, family member, and/or legal representative upon admission to the facility. This failure had the potential for the residents to receive unnecessary care/treatment and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, for two of three residents (Residents 1 and 2) a discharge plan was developed upon admission to meet the individual discharge planning needs. This failure had the potential for the residents to not receive necessary care and services to address resident's discharge needs and goals.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate medical transfer to an acute hospital emergency department was provided to one of two residents reviewed (Resident 3). This failure had the potential to result in actual or potential harm to Resident 3's physical, mental, and/or psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' mail was protected for privacy and confidentiality for one of three sampled residents (Resident 1), when the mailbox was not locked. This deficient practice had the potential for confidential information's, personnel letters, sensitive documents to be accessed by unauthorized individual.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comfortable environment was provided, for eight of eight residents (Residents 40, 36, 28, 15, 17, 32, 48, and 53), when the temperature in the resident's rooms were above 81 degrees Fahrenheit. On August 5, 2024, at 7:51 p.m., the Administrator (ADM), the Director of Nursing (DON), and the Director of Staff Development (DSD), were verbally notified of the Immediate Jeopardy (IJ-situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death, to a resident), due to the facility's failure to provide a comfortable environment for eight residents (Residents 40, 36, 28, 15, 17, 32, 48, and 53) when the resident's room temperature were above 81 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review, the facility failed, for three of five residents reviewed for unnecessary medication (Residents 5, 53, and 56), to ensure: a. An assessment was conducted for the continued use of antipsychotic medications (medication to treat mental disorders) for Residents 5, 53 and 56; and b. Monitoring for the use of hypnotic medication (medication use to help people fall asleep) for Resident 56. These failures had the potential for Residents 5, 53 and 56 to not be properly monitored and to receive unnecessary medications that could cause harm and or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when [NAME] (CK) 1 and Dietary Aide (DA) 1 were unable to accurately verbalize the cool down process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness resulting from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment, prepare, and served food in accordance with professional standards for food service safety, when multiple sheet pans were found with brown-black discoloration. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee monitored and re-evaluated identified concern regarding hot temperature levels in resident rooms (rooms 22, 23, 24 and 25). This failure resulted in unsafe and uncomfortable temperature levels (above 81 degrees Fahrenheit) in resident rooms, affecting the quality of care, quality of life, and resident safety (cross-reference F584).

Inspectors wroteBased on interview and record review, the facility failed to ensure education and resources regarding Advance Directive (AD - written statement of a person's wishes regarding medical treatment) were provided to the residents and/or resident reresentatives, for three of eight residents reviewed for Advance Directives (Residents 40, 46, and 54). This failure had the potential for Residents 40, 46, and 54 and the resident representatives uninformed about AD which could result in the facility being unable to know and honor the residents' wishes regarding their medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of six residents reviewed (Resident 32), the resident was able to voice a grievance without feeling uncomfortable. This failure had the potential for Resident 32's concerns to go unaddressed, leading to ongoing dissatisfaction and affecting the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication Carvedilol (medication used to treat high blood pressure) was administered as directed by the licensed nurse, for one of nine residents observed for medication administration (Resident 47). This failure has the potential for the resident to experience adverse effects of the medication if not taken as directed.

Inspectors wroteBased on observation, interview, and record review, the facilty failed to ensure Licensed Vocational Nurse (LVN) 1 was provided adequate training in the documentation of a narcotic pain medication administration for two of three residents reviewed (Residents 6 and 14). This failure has the potential to result in inaccurate assessment of the resident's pain and documentation of pain medication administration.

Inspectors wroteBased on interview, and record, review, the facility failed to ensure the licensed nurse documented the medication Hydrocodone-Acetaminophen (controlled drug pain medication) as administered for one of three residents reviewed (Resident 34). This failure resulted to the delay in the identification of drug discrepancies and possible medication diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely dental services for one of nine residents, (Resident 21). This failure had the potential to lead to mouth pain, infection, and/or complications related to dental and nutritional needs for Resident 21 if left untreated.

Inspectors wroteBased on observation and interview the facility failed to ensure for one of one resident (Resident 54) a pest free environment when one fly was observed on resident 54's lunch meal. This failure had the potential to place Resident 54 at risk for food borne illness (illness caused by food contaminated with bacteria) that can cause sickness and or death.

Inspectors wroteBased on interview and record review, the facility failed to address a doctor's concern regarding ongoing weekly telephone appointment for one of four sampled residents (Resident 1). This failure resulted for Resident 1 not receiving necessary care that he needed to achieve his highest level of physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's rights were respected, for one of four residents reviewed (Resident 1), when the facility cordless phone was not accessible for private conversations. This failure increased the potential to negatively affect Resident 1's psychosocial well-being.

Inspectors wroteBased on interveiw and record review, the facility failed to: 1) Administer medications as prescribed to 3 out of 3 Residents (Resident 1,2 and 3). 2) Order controled drug Xanax (An anti-anxiety medication) and failed to assure the medication was made available to Resident 1 as per Physician orders. This failure had the potential to: 1) Subject Resident ' s 1, 2 & 3 to negative health effects, due to not receiving their medications, as prescribed by the physician. 2) Subject Resident 1 to untreated feelings of anxiety, and withdrawl side effects from anti-anxiety medication Xanax.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of five residents (Resident 1). This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure Resident 1's care plans were reviewed and updated to meet the resident needs, and is made readily accessible for the staff to implement a consistent approach in keeping the resident free from fall and accident. The facility failure had resulted for Resident 1 to experience a fall when intervention in place was not meeting the resident's need to keep herself supervised, safe, and free from accident on July 27, 2023, at 2:22 a.m. Furthermore, the facility had failed to make Resident 1's care plan readily accessible to staff to provide a consistent approach in keeping Resident 1 safe and free from accident/injury.

Inspectors wroteBased on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure services that meet standards of care for resident supervision was met when Certified Nursing Assistant 1 (CNA) went on a break and had not properly endorsed Resident 1 was confused and disoriented. The facility failure had resulted for Resident 1 to fall on July 27, 2023, at 2:22 a.m. while CNA 1 was on her break.

Inspectors wroteBased on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure Resident 1's psycho-active medications were reviewed to be kept at a minimum to prevent excessive doses and to minimize adverse consequences. The facility failure had the potential for Resident 1 to experience potential risks (i.e., sedation) associated with over medication and duplication.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure for one of three sampled residents (Resident 2) when the facility failed to obtain the signatures for disposition of resident's belongings at discharge. This failure had the potential for Resident 2 to lose personal property.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders for one of three sampled residents (Resident 1) when the facility did not record input for Resident 1. This failure had the potential to cause fluid imbalance for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of four residents (Resident 1). This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the resident's room temperatures were maintained at a comfortable level (between 71-81 degrees) for 15 out of 32 rooms, when the rooms were found with temperatures above 81 degrees. This failure had the potential for the residents to feel uncomfortable and had the potential to increase the risk of dehydration and heat exhaustion in an already vulnerable population.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy and procedure on personal belongings when: 1. Personal inventory forms were not completed for three of three sampled residents (Resident 1, Resident 2 & Resident 3); and 2. Resident's personal clothing items were not labeled. These failures resulted in the sample residents losing personal items and had the potential for the facility residents receiving laundry service to lose personal clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary food preparation and storage practices in the kitchen, for 51 of 53 residents receiving an oral diet, when the ice machine's evaporator (where ice was formed) was noted to have brown residue build-up, and the ice chute had slimy yellowish-brown residue build-up. In addition, the facility was not monitoring the cleanliness of the ice machine. These failures had the potential to cause food-borne illness in a highly susceptible population of 51 out of 53 residents who were on an oral diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menus were followed when: 1. Six of six residents on a puree (smooth consistency foods) diet, received 1/3 cup of the meat but should have received 1/2 cup. 2. 11 of 11 residents on mechanical soft (a texture-modified diet that restricts foods that are difficult to chew or swallow) diet, received three ounces of meat and 1/3 cup of vegetable but should have received four ounces of meat and a 1/2 cup of vegetables. 3. Ten of ten residents on regular (not include any dietary restrictions) diet, received 1/3 cup of the vegetables but should have received 1/2 cup. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were able to receive and consume food brought by family and visitors. This failure limited residents from enjoying favorite foods and reduced resident food options and choices that could lead to weight loss for a medically compromised population of 53 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control program to prevent transmission of communicable disease and infection, when: 1. One licensed nurse was observed entering the PUI (person under investigation due to unknown COVID-19 [Corona Virus Disease 2019- an infectious disease caused by the SARS-CoV-2 virus, that can be transmitted from person to person]) room without appropriate personal protective equipment (PPE-gown, mask, shield/goggles, gloves and N95 mask, used in combination or alone). ; 2. The Treatment Nurse (TN) was observed donning and doffing gloves multiple times without performing hand hygiene in-between, while performing wound care to Resident 32's wound on the right heel. ; 3. [...]