Health inspection·December 23, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) /psychologist (a person who specializes in the study of mind and behavior) consult was provided timely for an acute change in condition as ordered for one of two sampled residents (Resident 1) in accordance with the Physician's order, care plan, and facility policy. This failure resulted in no psychiatric consultation (evaluation) for 25 days, with the potential for Resident 1 to experience a decline in mental and/or psychosocial (having to do with the mental, emotional, social, and spiritual) wellbeing and/or a lack of services/treatments to maintain or attain Resident 1's highest practicable mental and psychosocial wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (heart problems caused by long-term high blood pressure) with heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS -resident assessment tool), dated 10/31/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting hygiene, dressing, and personal hygiene. During a review of Resident 1's Order Summary Report, dated 11/25/2025, the Order Summary Report indicated for a psychiatrist/psychologist consult. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents) , dated 11/25/2025, the SBAR indicated Resident 1 with a behavioral change of verbal aggression towards a department of Public Health (DPH) surveyor and refusal of blood glucose fingerstick, with a doctor's recommendation from psychologist/psychiatrist consult. During a review of Resident 1's Episode of Profane Language care plan, dated 11/25/2025, the care plan indicated the intervention of psychiatrist/psychologist consult. During an interview on 12/22/2025 at 2:34 PM with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 experienced a behavioral change of condition on 11/25/2025 and a psychiatrist/psychologist consult was ordered. During an interview on 12/22/2025 at 3:40 PM with Psychiatrist 1, Psychiatrist 1 stated he was the psychiatry consultant for the facility and was not made aware Resident 1 had a psychiatry consult ordered on 11/25/2025 for an acute behavior change. Psychiatrist 1 stated he was at the facility on 12/21/2025 conducting routine rounds on other residents and was then informed by facility staff for the first time to consult with Resident 1. Psychiatrist 1 stated, he completes an evaluation once informed by nursing staff anytime a resident needs to be evaluated. Psychiatrist 1 stated he conducts resident evaluations when there is an acute episode of behavioral changes to evaluate for Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055203 Printed: 05/15/2026 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 055203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Village Care Center 1428 S. Marengo Ave. Alhambra, CA 91803 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)