TORRANCE, CA - State health inspectors documented numerous violations at Sunnyside Nursing Center during a February 2025 inspection, identifying failures in medication security, infection control practices, and dietary services that placed residents at risk for harm. The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care.
Medication Security Compromised Multiple Times
Inspectors found significant medication management failures that created opportunities for unauthorized access and potential drug diversion. During a medication pass observation, Licensed Vocational Nurse 2 left a medication cart unlocked and unattended in the hallway while administering medications to a resident behind a closed privacy curtain. The cart remained out of the nurse's view, accessible to anyone passing through the corridor until another nurse noticed and secured it.
More concerning was the discovery of controlled substances improperly stored in a medication cart. Inspectors found Lorazepam, an anxiety medication with potential for abuse, stored in a medication cart without a physician's order for the resident whose name appeared on the bottle. The medication belonged to Resident 390, who had Alzheimer's disease and lacked capacity to make medical decisions. When questioned, nursing staff stated "the Lorazepam should have been removed from the medication cart and taken to the DON" and acknowledged that storing unauthorized controlled substances in the cart created risks for medication errors and drug diversion.
The inspection also revealed that Resident 28's inhaled respiratory medication lacked proper dating after opening. Without an open date on the foil pack, nurses could not determine when the medication would expire according to manufacturer guidelines requiring use within two weeks of opening. This oversight could result in administering medication that had lost potency, potentially leaving the resident's breathing difficulties untreated.
Widespread Infection Control Failures Documented
The facility demonstrated multiple infection control violations that increased risks for disease transmission throughout the building. Inspectors observed oxygen tubing and bags for two residents that lacked required weekly change dates, making it impossible to determine how long equipment had been in use. Bacteria can colonize respiratory equipment over time, potentially causing pneumonia or other respiratory infections when contaminated equipment remains in service beyond recommended timeframes.
Similar dating issues affected tube feeding equipment. Resident 218's feeding and water bags lacked labels indicating when they were last changed, despite requirements for daily replacement. Bacterial growth in feeding equipment can cause serious gastrointestinal infections, particularly dangerous for residents with compromised immune systems.
A particularly troubling incident involved a visitor entering the room of Resident 169, who had tested positive for Candida Auris, without wearing required protective equipment. C. Auris represents a serious health threat as this yeast causes severe infections that resist most antifungal medications and spreads easily through contact with contaminated surfaces. The visitor sat beside the resident's bed wearing only a surgical mask, despite posted isolation signs and an available PPE cart at the room entrance. Staff acknowledged the visitor "should be wearing a PPE when visiting" but had not provided education about the infection control requirements.
Additional infection control lapses included a nurse exiting a COVID-positive resident's room while still wearing contaminated protective equipment, and staff failing to properly clean fecal contamination from a resident's floor. In the latter incident, a nursing assistant wiped feces from the floor with dry towels but failed to call housekeeping for proper disinfection, leaving contamination that could spread infectious organisms.
Dietary Services Unable to Meet Resident Preferences
The kitchen repeatedly failed to provide requested food items, affecting residents' nutritional intake and satisfaction. Resident 76, who required a controlled carbohydrate diet for diabetes management, reported that the kitchen "always run out of gravy, chicken noodle soup, bacon or cream of wheat." Staff confirmed these shortages occurred regularly, with popular items depleted before all residents received meals.
Kitchen staff acknowledged the problem, with one aide explaining that residents whose rooms had even numbers consistently received trays last and often missed out on preferred foods. When specific items ran out, residents received substitutions that did not match their documented preferences or dietary requirements. The assistant cook admitted the kitchen should prepare adequate quantities to meet resident requests, noting that failure to receive preferred foods could affect appetite and lead to weight loss.
Food safety violations compounded these service failures. Inspectors found Lysol bleach cleaner stored on a shelf in the dry food storage area, creating contamination risks if the chemical leaked onto food products. Prepared foods in refrigerators lacked required preparation and expiration dates, making it impossible to determine food safety. The ice machine drain contained visible dirt and debris that could harbor bacteria, and freezer temperature logs showed missing entries despite requirements for monitoring every shift.
Additional Issues Identified
Beyond these major violations, inspectors documented failures in the facility's quality assurance program to establish monitoring systems for medication errors, falls, and pressure ulcers. The facility could not demonstrate how it tracked or prevented these common nursing home problems despite having policies requiring such oversight.
The antibiotic stewardship program failed to function properly when Resident 98 received antibiotics without meeting established criteria for treatment. Staff had not notified the physician that the resident's symptoms did not justify antibiotic use, potentially contributing to antibiotic resistance.
Vaccination tracking showed gaps, with multiple residents lacking documentation that they had been offered or educated about influenza and COVID-19 vaccines for the 2024-2025 season. These oversights left vulnerable residents unprotected against preventable respiratory infections.
Physical plant issues included 83 resident rooms measuring less than the required 80 square feet per person in multi-occupancy rooms, though the administrator claimed this had not affected care delivery.
Medical Context and Industry Standards
These violations represent fundamental breakdowns in nursing home care standards. Medication security protocols exist because nursing home residents often take multiple medications with complex interactions, and unauthorized access can lead to dangerous medication errors, overdoses, or drug diversion. Industry standards require all medication carts to remain locked when unattended, with controlled substances subject to additional security measures including proper documentation and restricted access.
Infection control represents a critical safety issue in nursing homes where residents live in close quarters with compromised immune systems. Respiratory equipment requires regular replacement because moisture creates ideal conditions for bacterial and fungal growth. Studies show contaminated oxygen delivery systems can cause ventilator-associated pneumonia, with mortality rates reaching 30% in elderly populations. Similarly, tube feeding equipment can harbor dangerous pathogens that cause aspiration pneumonia when bacteria from contaminated feeding tubes enter the lungs.
The presence of Candida Auris requires exceptional vigilance. This emerging pathogen spreads rapidly in healthcare settings and resists most available treatments. Once established in a facility, C. Auris can persist on surfaces for weeks and colonize residents who then serve as reservoirs for transmission. Proper use of contact precautions, including gowns and gloves for all room entries, represents the primary defense against facility-wide outbreaks.
Nutritional services directly impact resident health outcomes. Malnutrition affects up to 50% of nursing home residents and correlates with increased infections, pressure ulcers, falls, and mortality. When facilities fail to accommodate food preferences or ensure adequate food availability, residents may reduce intake, accelerating functional decline. For diabetic residents like Resident 76, consistent access to appropriate foods helps maintain blood sugar control and prevent complications.
Proper food storage and temperature monitoring prevent foodborne illness outbreaks that can devastate nursing home populations. The CDC reports that adults over 65 face higher risks for severe foodborne illness due to weakened immune systems and decreased stomach acid production. A single contamination event from improperly stored chemicals or temperature-abused foods can affect dozens of residents simultaneously.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunnyside Nursing Center from 2025-02-15 including all violations, facility responses, and corrective action plans.
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