Inspection·December 8, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reasonable person in the patient's condition and circumstances would consider material to a decision to accept or refuse a proposed treatment or procedure;- Each resident has the right to participate in their healthcare planning and decision making including the request, refusal, and/or discontinue treatment, and the right to receive written disclosure in a language they understand;- A copy of the signed, written consent must be given to the resident or their representative.;- It is the responsibility of the prescribing physician, or approved licensed healthcare provider, to personally examine and obtain written informed consent, whereby applicable and indicated by state & federal regulations, from a resident or their representative for the use of:a. Physical restraints.b. Psychotherapeutic medications, and/orc. The prolonged use of a device that may lead to the inability to regain use of a normal bodily function; and- The licensed nurse receiving an order for a restraint or psychotherapeutic medication will not apply the restraint or administer the medication until verification of a written informed consent signed by the prescribing physician is documented in the resident's medical record. Medical record review for Resident 2 was initiated on 12/4/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/3/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's BIMS score was 00, indicating severe cognitive impairment. On 12/4/25 at 1100 hours, an observation and concurrent interview was conducted with the Activity Assistant. The Activity Assistant verified Resident 2 had a lap buddy and pad alarm on the wheelchair. The Activity Assistant stated Resident 2 had episodes of leaning forward, and the pad alarm and lap buddy would alert staff if the resident got up by himself or needed assistance. On 12/4/25 at 1220 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 2 was sitting in the wheelchair with the pad alarm and lap buddy. Review of Resident 2's medical record failed to show a physician's order and informed consent were obtained; and a care plan was developed for the use of the lap buddy and pad alarm on the wheelchair. On 12/4/25 at 1304 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no physician's order, informed consent, or care plan for Resident 2's lap buddy and pad alarm. On 12/4/25 at 1643 hours, an interview was conducted with the ADON. The ADON stated devices like alarms, lap buddies or trays were considered restraints when the indication was not appropriate for the resident. In addition, the licensed nurses must complete a device or restraint assessment, obtain a physician's order, consent prior to using or applying the device, and develop a care plan. On 12/8/25 at 1625 hours, an interview was conducted with the Administrator and ADON. The Administrator and ADON were informed and acknowledged the above findings. Event ID: Facility ID: 555733 If continuation sheet Page 2 of 4 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 12/08/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 two of five sampled residents (Resident 2 and 3). * The facility failed to ensure Resident 2's abnormal Neurological Assessment findings were reported to the physician. * The facility failed to ensure Resident 3 was monitored post fall on 12/2/25, for the morning and night shifts. These failures posed the risk of the residents not receiving appropriate care and the potential for a delay in providing care to the residents.Findings: Review of the facility's P&P titled Neurological Exam revised 3/2023 showed the following:- A neurological exam, also called a neuro exam, is an evaluation of a person's nervous system that can be completed in the healthcare setting;- The licensed nurse completes the neurological assessment flow record in accordance with documented time intervals;- Results will be documented in the residents' medical record;- Noted changes in the resident's neurological assessment from their usual baseline will be reported to the physician; andThe major areas of the exam, covering the most testable components of the neurological system, include:a. Level of Consciousnessb. Pupil Responsec. Hand Grasps d. Extremitiese. Pain Response f. Vital Signsg. Observation. Review of the facility's P&P titled Documentation revised 3/2023 showed the following:72-hour charting shall be initiated at the following times - this list is not all inclusive and nursing may use their judgment based on clinical condition.a. Significant change in physical, mental, or psychosocial status of the resident (progression, regression, new problems); andb. An extraordinary event occurs (e.g. fall or injury). Review of the facility's P&P titled Fall Management Program revised 3/2023 showed the following:After a fall or other similar accident, the resident shall have a physical assessment documented in the nursing notes in accordance with the general facility policy on documenting by exception. The attending physician and resident representative or interested family member shall be notified of the incident; and- The facility shall begin charting for a minimum of 72 hours after the fall or related accident and continue to assess for latent injuries or changes in condition. 1. Medical record review for Resident 2 was initiated on 12/4/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/3/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's BIMS score was 00, indicating severe cognitive impairment. Review of Resident 2's Progress Note dated 11/26/25, showed at around 0430 hours, the resident was found laying on his right side facing away from the bed. The resident had an open laceration on his forehead on the right side above his right eye.PERRLA 4 mm.resident was at baseline neuro. Neuro check was initiated for 72 hours. Received orders to transfer the resident to the emergency room, resident left at 0530 hours to go to the acute care hospital. Review of Resident 2's Progress Note dated 11/26/25, showed at around 1700 hours, the resident returned to the facility from the acute care hospital. Review of Resident 2's 72 Hour Neurological assessment dated [DATE], showed to inform the attending physician if there was a deviation from the resident's normal status. Further review of the document showed the key legend for pupil reaction was coded 1 for brisk, 2 for sluggish, and 3 for fixed. The document showed Resident 2 had the following abnormal findings for the right and left pupil reaction when the resident returned to the facility from the acute care hospital:- dated 11/26/25 at 2015 hours, ‘3' for fixed right and left pupil reaction; and- dated 11/27/25 at 0815, 1215, 1615, and 2015 hours, ‘3' for fixed right and left pupil reaction. Review of Resident 2's medical record failed to show documented evidence the resident's physician was notified of the abnormal neurological findings when the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 3 of 4 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 12/08/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete readmitted to the facility on [DATE] at 1700 hours. On 12/8/25 at 1522 hours, an interview and concurrent medical record review for Resident 2 was conducted with the ADON. The ADON verified Resident 2's fixed pupil reaction were abnormal findings and should have been reported to the physician. The ADON stated the physician should have been notified and the notification should have been documented. 2. Medical record review for Resident 3 was initiated on 12/4/25. Resident 3 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 11/28/25, showed Resident 3 had fluctuating capacity to understand and make decisions. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3's BIMS score was 15, indicating intact cognition. Review of Resident 3's SBAR dated 12/2/25, showed the resident experienced an unwitnessed fall on 12/2/25, at around 0410 hours. Review of Resident 3's medical record failed to show documented evidence the resident was monitored post fall on 12/2/25, for the morning (0700-1500 hours) and night shift (2300-0700 hours). On 12/4/25 at 1643 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified there was no documentation in the medical records to show Resident 3 was monitored on the morning and night shift post fall on 12/2/25. The ADON stated after a change of condition including an unwitnessed fall, the licensed nurses must complete a SBAR, incident report, assessments of pain, skin, and fall risk, 72 hours neurological assessment, notify physician and the responsible party, develop and/or update the care plan, and 72 hours documented monitoring of resident's well-being following a fall. On 12/8/25 at 1625 hours, an interview was conducted with the Administrator and ADON. The Administrator and ADON were informed and acknowledged the above findings. Event ID: Facility ID: 555733 If continuation sheet Page 4 of 4