Federal Nursing-Home Survey Record
THE PAVILION AT SUNNY HILLS
Does THE PAVILION AT SUNNY HILLS have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), THE PAVILION AT SUNNY HILLS (CCN 555733), in FULLERTON, CA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 34 deficiencies; the most serious carries scope/severity E on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2025-04-28. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 3.2
Deficiency timeline — full federal history
Provide enough food/fluids to maintain a resident's health.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Provide and implement an infection prevention and control program.
Keep all essential equipment working safely.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
PASARR screening for Mental disorders or Intellectual Disabilities
Keep residents' personal and medical records private and confidential.
Ensure each resident receives an accurate assessment.
Allow residents to self-administer drugs if determined clinically appropriate.
Dispose of garbage and refuse properly.
26 citations from earlier inspection cycles — historical, not current (expand)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide safe and appropriate respiratory care for a resident when needed.
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Allow residents to self-administer drugs if determined clinically appropriate.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Keep residents' personal and medical records private and confidential.
Dispose of garbage and refuse properly.
Keep all essential equipment working safely.
Document what happened
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