Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call
light was kept within reach for one of 18 final sampled residents (Resident 46). This failure had the potential
for the resident to not be able to use the call light to summon assistance.
Residents Affected - Few
Findings:
Review of the facility's P&P titled Answering the Call Light revised October 2010 showed under the section
for General Guidelines, Number five showed when the resident is in bed or confined to a chair, be sure the
call light is within easy reach of the resident.
On 12/12/22 at 0928 hours, Resident 46 was observed in bed with the call light button attached to the
headboard of the bed. The call light was situated between the bed and the wall, out of reach for Resident
46.
On 12/12/22 at 1032 hours, a concurrent observation and interview was conducted with CNA 2. Resident
46 was observed in bed with the call light attached to the headboard of the bed and out of reach. CNA 2
verified Resident 46's call light was out of reach for Resident 46. CNA 2 further stated Resident 46 calls for
help from staff by using the call light.
On 12/15/22 at 1408 hours, Resident 46's call light was observed on the floor on the left side of the bed.
On 12/15/22 at 1410 hours, an interview was conducted with the help of a Korean translator with Resident
46. When asked how Resident 46 called for help, Resident 46 was observed activating the call light. When
Resident 46 was asked why they activated the call light, Resident 46 responded, when I press the button,
someone will come and help me.
On 12/15/22 at 1427 hours, a concurrent interview and observation was conducted with CNA 3. CNA 3 was
asked to come to Resident 46's room. CNA 3 verified Resident 46's call light was on the floor, out of reach
for Resident 46. CNA 3 stated Resident 46 used the call light when the resident required help from the staff.
Medical record review for Resident 46 was initiated on 12/15/22. Resident 46 was admitted to the facility on
[DATE].
Review of Resident 46's care plan dated 10/24/21 and revised 7/27/22, showed under focus, the resident
was at risk for falls related to impaired cognition,self-care deficits, and history of repeated
(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 10
Event ID:
555266
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
falls. The careplan interventions included to place the resident's call light within reach and encourage the
resident to use it for assistance as needed, and the resident needed prompt responses to all requests for
assistance.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 2 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure the personal privacy for two
of 18 final sampled residents (Residents 48 and 66) when:
Residents Affected - Few
* Resident 48's curtain was not completely closed while the G tube medications were being administered.
* Resident 66's room had a Hard of Hearing posting stapled above the head of bed.
* Personal health information (PHI) on a computer terminal was left unattended with visible resident
identifier information.
These failures had the potential to negatively affect the dignity of the residents and violate privacy.
Findings:
Review of the facility's P&P titled Confidentiality/Security of Information revised 9/20/09, showed all
information, both automated and manual, regarding specific residents, applicants for admission or related
health information pertaining to a resident, is protected by law and must be secured against loss,
destruction and unauthorized access or use. According to the P&P, automated and manual resident's
records/information systems are subject to the same degree of management control, protections, integrity,
reliability, accessibility, verification of accuracy and security. The objectives of information security are
designed to ensure residents' privacy and protection of health information/data; protection of
communications (manual or automated systems) as they relate to a resident, facility, or the organization.
Review of the facility's P&P titled Health Information/Record Manual-Confidentiality/Security of Information
revised 9/20/09, under Policy, Number one showed all information, both automated and manual regarding
specific residents, applicants for admission or related health information pertaining to a resident is
protected by law and must be secured against loss, destruction and unauthorized access or use.
1. On 12/14/22 at 0828 hours, a medication administration observation was conducted with RN 2 in
Resident 48's room. RN 2 checked Resident 48's G tube placement and residual. RN 2 did not pull
Resident 48's privacy curtain prior to accessing the resident's G tube site for medication administration.
On 12/14/22 at 0908 hours, an interview was conducted with RN 2. RN 2 was asked about Resident 48's
privacy curtain. RN 2 confirmed she did not pull the curtain all the way around the resident to ensure the
privacy. RN 2 verified the privacy curtains should have been pulled around Resident 48's bed right away to
provide sufficient privacy.
2. On 12/12/22 at 1043 hours, an observation of Resident 66 was conducted in the resident's room.
Resident 66 was observed in bed and awake. A Hard of Hearing posting was observed stapled above
Resident 66's head of the bed, indicating the resident was hard of hearing. The posting was not covered.
On 12/12/22 at 1047 hours, an interview was conducted with RN 1. RN 1 stated the posting indicated
Resident 66 was hard of hearing and verified it violated HIPAA.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 3 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 12/13/22 at 1606 hours, an interview was conducted with the DON. The DON stated Resident 66's
posting should have been covered to protect privacy.
b. During an observation on 12/15/22 at 1444 hours, a computer monitor displayed with resident information
was left unattended at Nursing Station 1. The computer monitor displayed resident pictures, dates of birth,
diagnoses, and allergy information.
On 12/15/22 at 1448 hours, a concurrent observation and interview was conducted with RN 1. RN 1 verified
the computer was left unattended and stated anyone could have accessed the resident's information. RN 1
stated the computer monitor with resident information should not be left unattended.
3a. During an observation on 12/12/22 at 1200 hours, a laptop computer on the medication cart was left
open at Nursing Station 2. The laptop computer screen faced the hallway where other residents were
observed and displayed a resident's personal information including diagnoses, allergies, and picture.
On 12/12/22 at 1208 hours, a concurrent observation and interview was made with the DSD. The DSD
verified the laptop computer was left unattended and showed resident information. The DSD acknowledged
the laptop computer should not be left unattended with visible resident identifier information because it was
a privacy concern.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 4 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18
final sampled residents (Resident 50) received care in accordance with standards of practice.
Residents Affected - Few
* Resident 50 received dialysis treatment (process of removing waste products and excess fluid from the
body). The facility failed to place a dressing on Resident 50's tunneled dialysis catheter (a thin flexible
hollow tube that is tunneled under the skin before entering a large vein) insertion site. This failure had to
potential for Resident 50 to develop a central line-associated bloodstream infection (CLABSI, a serious
infection that occurs when germs enter the bloodstream through the central line)
Findings:
According to the facility's P&P titled Central Venous Catheter Dressing Change dated 6/2018 under the
section for Policy, Letter A, the P&P showed a transparent dressing (a thin, clear sterile dressing that keeps
out water, dirt and germs) is the preferred dressing. If the resident is allergic to the transparent dressing, a
gauze and tape dressing may be used.
Medical record review for Resident 50 was initiated on 12/13/22. Resident 50 was admitted to the facility on
[DATE]. Resident 50 had a diagnosis of end stage renal disease (ESRD, last stage of chronic kidney
disease when the kidneys fail and stopped working well enough to survive) and was on hemodialysis.
Review of Resident 50's MDS dated [DATE], showed the resident had severe impaired cognitive skills
(mental action or process of acquiring knowledge and understanding) for daily decisions making. The MDS
also showed the resident required extensive assistance with bed mobility, transfers, dressing, toilet use,
personal hygiene, and bathing.
Review of Resident 50's Order Summary Report dated 12/14/22, showed an order dated 12/10/22, to
monitor the hemodialysis access site on the right upper chest tunneled catheter for signs/symptoms of
infection.
On 12/14/22 at 1500 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2
confirmed the tunneled dialysis catheter on Resident 50's right upper chest was open to air with no
dressing applied to the insertion site. LVN 2 stated the tunneled dialysis catheter should have a dressing
applied to the insertion site due to the risk of infection.
On 12/15/22 at 0914 hours, an interview was conducted with RN 1. RN 1 stated tunneled dialysis catheters
should be covered with an occlusive dressing (a thin, clear dressings that usually have an adhesive side
that faces the wound). When asked why it was important to keep central lines covered, RN 1 stated
because of the risk of infection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 5 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation and interview, the facility failed to ensure a stored medication bottle was properly
labeled to include an expiration date. This failure had the potential for the residents at the facility to receive
expired medications.
Findings:
On 12/15/22 at 1450 hours, an inspection of Medication Cart A and concurrent interview was conducted
with RN 2. Medication Cart A was observed to have a bottle of Geri-Tussin DM (also known as
dextromethorphan-guaifenesin, a combination medication used to relive coughs) with an expiration date of
09/ with the year crossed out. RN 2 confirmed she could not determine the medication's expiration date and
stated the Central Supply Personnel was responsible for encircling the expiration date.
On 12/15/22 at 1502 hours, an interview was conducted with the Central Supply Personnel. The Central
Supply Personnel confirmed she was responsible for encircling the expiration dates on the medication
bottles. The Central Supply Personnel verified the expiration date labeled on the Geri-Tussin DM bottle was
circled with a black marker, thus covering the year of expiration. The Central Supply Personnel stated she
made a mistake. When asked if she knew when the bottle of Geri-Tussin DM expired, the Central Supply
Personnel stated no.
On 12/15/22 at 1506 hours, a follow-up interview was conducted with RN 2. When asked if the Geri-Tussin
DM should be administered without knowing the correct expiration date, RN 2 stated no.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 6 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview, the facility failed to ensure the food was prepared and served in
accordance with professional standards for food safety as evidence by:.
Residents Affected - Some
* The facility failed to ensure the food which was prepared to be served to the residents from the kitchen
was free from chemical contamination.
* The facility failed to maintain the temperatures of the milk were appropriate when served to the residents.
These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population
who consumed food prepared in the kitchen.
Findings:
Review of the CMS 672 form completed by the facility dated 12/12/22, showed 63 residents received the
food prepared in their dietary department.
1. On 12/14/22 at 1109 hours, an observation of [NAME] 1 during the puree preparation was conducted.
[NAME] 1 was observed washing the items used for puree in the sink. Then with gloved hands [NAME] 1
was observed moving the items to the section of the sink filled with fluid, which appeared light pink in color.
[NAME] 1 then took a knife from another kitchen staff member and begun cutting a food item which [NAME]
1 identified the food item as a sheet of chocolate peanut butter bars. Fluid from the outside of [NAME] 1's
gloves was observed dripping from the gloves and onto the food as the cook cut the chocolate peanut
butter bars. [NAME] 1 then scooped several of the cut chocolate peanut butter bars from the tray and
placed them into the blender. When asked, [NAME] 1 verified he was going to blend the chocolate peanut
butter bars to serve to the residents.
During a concurrent interview with the Dietary Supervisor, the Dietary Supervisor was asked if she
observed the liquid on the sheets of chocolate peanut butter bars, the Dietary Supervisor stated yes. When
asked what the fluid was, the Dietary Supervisor stated it was condensation. When asked if the Dietary
Supervisor could observe fluid on the outside of [NAME] 1's gloves, the Dietary Supervisor stated yes.
When asked if there should be fluid on the outside of [NAME] 1's gloves, the Dietary Supervisor stated no.
When asked why it was a concern, the Dietary Supervisor stated the concern was for chemical and
sanitation contamination of the food.
2. Review of the facility document titled Lunch Milk Beverage Production List dated 12/14/22, showed the
following:
* three residents was to receive 4 oz of soy milk
* three resident was to receive 4 oz of whole milk
* four residents was to receive 8 oz of soy milk
* four resident was to receive 8 oz of whole milk
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 7 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0812
* one resident was to receive 8 oz of nectar thickened soy milk
Level of Harm - Minimal harm
or potential for actual harm
* two residents was to receive 4 oz of two percent milk
* one resident was to receive 2 cups of 8 oz soy milk
Residents Affected - Some
* one resident was to receive 4 oz of nectar thickened soy milk
On 12/14/22 at 1212 hours, an observation and concurrent interview was conducted with the Dietary
Supervisor. When asked if the cups filled with liquid were prepared for the lunch trays and ready to be
served, the Dietary Supervisor stated yes. When asked if the kitchen was serving the drinks, the Dietary
Supervisor stated yes. When asked what temperature of the milk should be served at, the Dietary
Supervisor stated at 41 degrees Fahrenheit or below. During a concurrent observation and interview,
measurement of the temperatures of cold serviced fluids was conducted and showed the following:
- Temperature measuring of the first glass of fluid labeled milk showed the temperature was at 43 degrees
Farenheit.
- Temperature measurement of the second glass of fluid labeled soy milk showed the temperature was at
43 degrees Fahrenheit.
3. Temperature measurement of the third glass of fluid labeled milk showed the temperature was at 43
degrees Fahrenheit .
The Dietary Supervisor verified the above findings. When asked if the milk was safe to serve, the Dietary
supervisor stated no. When asked, the Dietary Supervisor stated there were eight residents who were to
receive whole milk, eight residents who were to receive soy milk, two residents who were to receive nectar
thick milk, and two residents who were to receive two percent milk.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 8 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, facility document review, and facility P&P review, the facility failed to implement the
infection control practices to prevent the spread of infection as evidenced by:
Residents Affected - Few
* The facility failed to follow the proper doffing practices before exiting a room on isolation precautions.
* The facility failed to ensure the staff performed hand hygiene before and after contact in between
residents.
These failures had the potential for cross-contamination and spread of infectious organisms in the facility.
Findings:
1. According to the CDC, under Precautions to Prevent Transmission of Infectious Agents reviewed 7/2019,
healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions
that may involve contact with the patient or potentially contaminated areas in the patient ' s environment.
Donning the PPE (personal protective equipment) upon room entry and discarding before exiting the
patient room is done to contain pathogens, especially those that have been implicated in transmission
through environmental contamination
On 12/14/22 at 0906 hours, an observation was conducted for Room B. Room B was observed with an
isolation signage indicating contact precautions should be observed. CNA 1 was observed walking out of
Room B into the hallway wearing an isolation gown while carrying bed linen in her arms. CNA 1 was next
observed disposing of the bed linen in the dirty clothes bin. CNA 1 walked to the clean linen cart, removed
the protective cover, put her hand inside the cart, and removed a clean linen. CNA 1 was then observed to
walk back into room [ROOM NUMBER] while the CNA was still wearing the same isolation gown.
On 12/14/22 at 0909 hours, an interview was conducted with CNA 1. CNA 1 verified she exited the room
while donning an isolation gown. When asked where the staff was expected to remove the isolation gowns,
CNA 1 stated inside of the room by the door entrance.
On 12/14/22 at 0947 hours, an interview was conducted with the IP. When asked if they would have a
concern if a staff walked out of a room wearing an isolation gown and carrying dirty linen, the IP answered
the staff was not to leave the resident's room in an isolation gown. When asked if there would be a concern
if a staff member reached into the clean linen cart wearing an isolation gown, the IP stated yes. When
asked to elaborate on the concern, the IP. stated it could cause a spread of infection.
2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 2017 showed in most situation,
the preferred method of hand hygiene was with an alcohol-based hand rub. If hands were not visibly soiled,
use alcohol-based hand rub containing 60-95% ethanol or isopropanol for situations including before and
after contact with the residents.
On 12/15/22 at 0951 hours, LVN 1 was observed entering Room A without performing hand hygiene. LVN
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 9 of 10
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
555266
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sun Mar Nursing Center
1720 West Orange Avenue
Anaheim, CA 92804
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
1 was observed touching Resident 18A on her shoulder. LVN 1 was then observed coming out of the Room
A without performing any hand hygiene after touching Resident 18A. LVN 1 was then observed to touch
Resident 422 (who was in a wheelchair in a hallway) on her hand and shoulder. LVN 1 was not observed
performing hand hygiene before touching Resident 422.
On 12/15/22 at 0955 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above
observation. LVN 1 acknowledged the observation and stated she should have performed hand hygiene
before entering and exiting the room of the residents and in between touching residents.
On 12/15/22 at 1018 hours, an interview was conducted with the IP. The IP acknowledged the above
findings. The IP stated staff should perform hand hygiene before and after contact with the residents. The IP
stated not performing hand hygiene before and after contact with residents may lead to transmission of
infection to other residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555266
If continuation sheet
Page 10 of 10
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 20, 2022 survey of SUN MAR NURSING CENTER?
This was a inspection survey of SUN MAR NURSING CENTER on December 20, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SUN MAR NURSING CENTER on December 20, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.