Health inspection·November 18, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean, comfortable and home-like environment two of six sampled residents (Resident 3 and Resident 4) by failing to ensure there were enough linen, incontinent pads (used to absorb leakage, reduce odors and control bacteria,) towels and blankets available to change for the residents.This failure had the potential to result in skin breakdown and negatively affect the psychosocial well-being of Residents 3 and 4.Findings:During an observation on 10/21/2025 at 11:45 a.m., the linen storage station 1 had no blankets and no incontinent pads. The linen cart station 1 had no blankets, no incontinent pads, no gowns, and no towels. The linen storage station 2 was observed with no blankets, no incontinent pads and no towels.During an observation on 10/21/2025 at 3:10 p.m., the linen storage station 2 was observed to have no blankets, no incontinent pads, no towels. The linen cart station 1 had no blankets, no incontinent pads, no towels. The linen storage station 1 had no blankets and no sheets.During an observation on 10/22/2025 at 4:53 a.m., the linen storage station 2 had no sheets. 1). A review of Patient 3's admission Record indicated Patient 3 was admitted to the facility on [DATE], with diagnoses including difficult in walking (gait disturbance,) spondylosis (a degenerative condition of the spine that affects the joints (facet joints) and discs between the vertebrae) and Chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).A review of Patient 3's History and Physical (H&P) dated 2/27/2025, indicated Patient 3 had the capacity to understand and make medical decisions.A review of Patients 3's Minimum Data Set (MDS - a Patient assessment tool) dated 9/9/2025, indicated Patient 3 had cognition intact. The MDS indicated Patient 3 required substantial to maximum assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility.During an interview on 10/21/2025 at 11:20 a.m., with Patient 3 in Patient 3's room, Patient 3 stated around 4:00 a.m. in the morning the nurses come and do incontinent care. Patient 3 stated I had not seen them changing all the sheets except my diaper. Patient 3 stated I would like to have fresh and clean blankets to cover me. 2). A review of Patient 4's admission Record, indicated Patient 4 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (neurological conditions that affect one side of the body,) metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic disturbance) and Diabetes Mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A review of Patient 4's H&P dated 8/29/2025, indicated Patient 4 had the capacity to understand and make medical decisions.A review of Patients 4's MDS dated [DATE], indicated Patient 4 had intact cognition. The MDS indicated Patient 4 required dependent assistance with ADLs such as dressing, toilet use, personal hygiene, transfer and mobility. During an interview on 10/21/2025 at 11:40 a.m., with Patient 4 in Patient 4's room. Patient 4 stated he needed assistance from nurses, for ADL care. Patient 4 stated nurses ran out Page 1 of 2 055737 055737 11/18/2025 Sunny Hills Post Acute 12200 LA Mirada Blvd. LA Mirada, CA 90638

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of sheets and towels around 2 a.m. to 4 a.m. Patient 4 stated when he asked the nurses to do incontinent care, the nurses only changed the diaper not the sheets. Patient 4 stated the nurses in the morning change the sheets. Patient 4 stated the nurses at nighttime tried to find sheets in the drawers or other places. Patient 4 stated he does not like sweaty sheets under him.During a concurrent observation and interview on 10/21/2025 at 3:10 p.m. with Laundry Assistant (LA) 1, LA 1 observed the linen storage closet station 2 with no blankets, no incontinent pads and no towels. LA 1 stated linen storage and carts are refilled with towels, gowns, blankets, incontinent pads, fitting sheets and cover sheets at 6:00 a.m., 1 p.m., and 4:30 p.m. The linen cart station 1 had no blankets, no incontinent pads, no towels. The linen storage closet station 1 had no blankets, no sheets. LA 1 stated at 1p.m., the linen storage and carts should have been refilled with enough linen. LA 1 stated she do not know why there are not enough linen in the storage rooms and carts. LA 1 stated the afternoon shift starts at 3 p.m., and it is important for the afternoon shift to have enough linen in the carts and storage rooms for Patient's needs. LA 1 state it is not acceptable for Patients to wait for linen to be changed.During an interview on 10/21/2025 at 4:00 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Patients are monitored for incontinent care at the beginning of the shift and every two hours. CNA 3 stated there were not enough linen at start of shift and by 11:00 p.m., there were issues with no blankets, towels and sheets. CNA 3 stated that when there is not enough linen, the Patients had to wait until the laundry department brings more linen. CNA 3 stated the risk of Patients being wet for long periods of time can cause skin breakdowns and skin infections. CNA 3 stated it was not safe for Patients to not have enough lining available for their care. During an interview on 10/22/2025 at 9:10 a.m., with Laundry Supervisor (LS), the LS stated linens were delivered around 6:30 a.m. and the linen storages and carts were refilled. The LS stated LA 2 will come and refill the linen around 2:30 p.m., before the afternoon shift starts and then at 7:30 pm., before the laundry closes. The LS stated it was very important to fill the linen cart before each shift because nurses need to take care of Patients. The LS stated the facility's responsibility was to provide comfort to Patients by providing clean blankets and sheets.During a review of the facility's Policies and Procedures (P&P) titled, laundry Aide Job Description, undated the P&P indicated the Laundry Aide is primarily responsible for collecting, stacking and stocking laundry, coordinating laundry services with nursing department.During a review of facility's P&P titled Safe and Homelike Environment dated 12/19/2022, the P&P indicated the facility will provide and maintain bed and bath linens that are clean. 055737 Page 2 of 2