Inspection·July 30, 2024

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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). Residents Affected - Few * The facility failed to follow up with the hospice for the latanoprost eye drop (to treat glaucoma) order for Resident 1. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Hospice Services revised March 2023 showed the nursing home staff may obtain the orders for care from the designated hospice physicians and communicate the necessary changes initiated by the hospice provider to the resident's attending physician/practitioner in a timely manner. The nursing home shall communicate changes in orders provided by the resident's attending physician/practitioner in the facility if he/she is not the resident's designated physician on the hospice team. Review of the facility's Hospice and Nursing Facility Services Agreement signed 4/4/24, showed when the facility personnel are directed by the hospice to administer the prescribed therapies to the residents who are under hospice's care, including those therapies determined appropriate by the hospice and delineated in the plan of care, the facility personnel shall administer the therapies in accordance with applicable law and thefacility policies and procedures. Review of Resident 1's medical record was initiated on 7/30/24. Resident 1was admitted to the facility on [DATE]. Review of Resident 1's physician's order for July 2024 showed an order dated 6/3/24, to admit the resident for hospice care. Review of Resident 1's MDS Change of Condition assessment dated [DATE], showed Resident 1 was able to make self-understood and understand others. Review of Resident 1's plan of care showed a care plan problem for actual impaired vision related to diabetes mellitus was initiated on 6/22/24, with the interventions to administer the medications as ordered and monitor for side effects and effectiveness. Review of Resident 1's hospice physician's order dated 6/29/24, showed an order for latanoprost (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: 555733 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 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)