Inspection·May 28, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medication administration was documented for one of three sampled residents (Resident 1). This failure had the potential for the medical record information to be not accurate for Resident 1. Findings: Review of facility's P&P titled Administering Medications revised March 2023 showed the medications must be administered in accordance with the orders. Medications must be administered in accordance with state and federal guidelines. Following verification of the resident and scheduled medication, the licensed nurse follows the pour, pass, chart standard of practice. Closed medical record review for Resident 1 was initiated on 5/27/25. Resident 1 was admitted in the facility on 4/23/25. Review of Resident 1's Order Summary Report dated 5/28/25, showed the following physician's orders: - dated 4/23/25, acetaminophen (pain reliever) 325 mg, give two tablets by mouth every four hours as needed for mild pain (1-3 pain scale) - dated 4/23/25, baclofen (muscle relaxant) 5 mg tablet, give onetablet by mouth every eight hours as needed for muscle spasm. Review of Resident 1's MAR for May 2025 failed to show two tablets of acetaminophen 325 mg and one tablet of baclofen 5 mg were documented as administered on 5/9/25 at approximately 1300 hours. Review of Resident 1's Progress Notes failed to show two tablets of acetaminophen 325 mg and one tablet of baclofen 5 mg medications were documented as administered on 5/9/25 at approximately 1300 hours. On 5/27/25 at 1112 hours, an interview was conducted with Family Member 1. Family Member 1 stated on 5/9/25, Resident 1 was given baclofen medication approximately 1300 hours. On 5/27/25 at 1437 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 stated he administered two tablets of acetaminophen 325 mg and one tablet of baclofen 5 mg orally between 1200-1300 hours to Resident 1 for pain and muscle spasm. LVN 1 verifiedhe failed to document the medications as administeredin the MAR. LVN 1 stated he should have documented in Resident 1's MAR after the medications were administered to prevent medication errors. (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 05/28/2025 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)