Sunnyside Nursing Center

F-F759

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31333 Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure:

1. One of four medications carts (Station 300 [NAME] Medication Cart (Med Cart) 2 was locked when not attended by the Licensed Vocational Nurse (LVN) 2.

This failure had the potential to result in visitors, residents, and staff unauthorized access to residents' medications.

2. One of two medication cart (Station Subacute Med Cart Red Zone) inspected which contained home medications (medications brought to the facility by a resident or family member) that included a controlled medication, Lorazepam (used to treat anxiety [emotion characterized by feelings of tension, worried thoughts] disorders) ,labeled for Resident 390 was not stored inside of Station Subacute Med Cart Red Zone without a physician order for the resident.

This failure of storing Lorazepam which was not a medication ordered by Resident 390's physician in Med Cart Red Zone increased the risk for medication misuse, drug diversion (when a medication is taken for use by someone other than whom it is prescribed), medication errors, and/ or resident harm.

3. Resident 25's Ipratropium-Albuterol Inhalation Solution (used to help control the symptoms of lung diseases) had an open date.

This failure had the potential to result in Resident 28 receiving medication that had become ineffective or toxic due to improper storage possibly leading to health complications or hospitalization .

Findings:

1. During a medication pass observation on [DATE REDACTED] at 12:35 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 after preparing medications for Resident 169, LVN 2 left Med Cart 2 in the hallway unlocked and entered Resident 169's room and closed the resident's privacy curtain. Med Cart 2 was observed in the hallway unattended, unlocked and out of the view of LVN 2.

During a concurrent observation and interview on [DATE REDACTED] at 12:37 p.m., Registered Nurse (RN) 1, noticed

the unlocked medication cart while LVN 2 was behind Resident 169's privacy curtain and pushed the button to lock Med Cart 2. RN 2 stated, the medication cart should have been locked.

During an interview on [DATE REDACTED] at 1:43 p.m., with LVN 2, LVN 2 stated the medication cart should have been completely closed, shut and locked to prevent someone from coming to take medications from the medication cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0761 During an interview on [DATE REDACTED] at 1:45 p.m., with RN 1, RN 1 stated, medication cart being locked is for safety and if left unattended or not locked there is a risk that other resident or staff could take medications Level of Harm - Minimal harm or from the medication cart and a potential for harm and medication error if a confused resident was to take potential for actual harm medication from the unlocked medication cart.

Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated [DATE REDACTED], indicated Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

2. During a review of Resident 390's Admission Record, the Admission Record indicated Resident 390 was admitted to the facility on [DATE REDACTED] with a diagnoses included Alzheimer's disease (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform daily tasks) and COVID-19 (a respiratory disease caused by coronavirus)

During a review of Resident 390's, History and Physical (H&P) dated [DATE REDACTED], the H&P indicated Resident 390 does not have the capacity to understand and make decisions.

During a concurrent observation and interview on [DATE REDACTED] at 10:22 p.m., with LVN 4 on Station Subacute Med Cart Red Zone, LVN 4 opened the Med Cart Red Zone and observed inside the locked drawer was a bag with bottles of medications labeled for Resident 390. LVN 4 stated the bag of medications belong to Resident 390 and were brought from resident's home and the facility was not using the resident's home medications. The medications included:

Lorazepam 0.5 milligrams (mg - unit of measure of weight)

Linzess (used to treat irritable bowel syndrome with constipation) 72 micrograms (mcg - unit of measure of weight)

Memantine (used to treat memory loss) 5 mg

Levothyroxine (used to treat low thyroid) 25 mcg

Meclizine (used to treat motion sickness like nausea, vomiting or dizziness) 25 mg

PreserVision AREDS 2 (supplement), the medication bottle did not include a label or include Resident 390's name on the bottle or instructions for use.

During an interview on [DATE REDACTED] at 10:50 a.m., with LVN 4, LVN 4 stated she was not aware that a controlled medication, lorazepam was stored inside the bag of home medications for Resident 390. LVN 4 opened the lorazepam bottle inside was four tablets, two were lorazepam and LVN 4 could not tell what medication the other two tablets were. LVN 4 stated Resident 390's home medication, lorazepam should have been accounted for, removed from the medication cart, and given to the Director of Nursing (DON) or returned to

the resident's family.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0761 During a concurrent interview and record review on [DATE REDACTED] at 11:02 a.m., with Registered Nurse (RN) 2 and LVN 4, Resident 390 physician Order Summary Report was reviewed. RN 2 stated there was no physician Level of Harm - Minimal harm or order of Lorazepam for Resident 390. RN 2 stated the Lorazepam should have been removed from the potential for actual harm medication cart and taken to the DON. RN 2 stated medication error or loss of medication could happen, when Resident 390's medications brought from home and no physician order were stored in the medication Residents Affected - Few cart available for use.

During a review of the facility's P&P titled, Medications Brought to the Facility by a Resident or Family Member, dated ,d+[DATE REDACTED], indicated Unauthorized medications are not accepted by the facility .Medications not ordered by the resident's physician or unacceptable for other reasons, are returned to the family or designated agent. If unclaimed within (thirty) days, the medications are disposed of in accordance with facility medication destruction/disposal procedures .Medication storage conditions are monitored on a monthly basis by the consultant pharmacist and corrective actions taken if problems are identified.

50144

3. During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE REDACTED] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular disease (condition that affect the blood vessels in the brain and spinal cord) affecting left non-dominant side and unspecified asthma (chronic lung disease).

During a review of Resident 28's MDS, dated [DATE REDACTED], the MDS indicated Resident 28's cognition was not intact, and was dependent for eating, hygiene, and bathing.

During a review of Resident 28's Physician Order Summary, the Physician Order Summary indicated an order for Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE REDACTED].5 (3) milligrams (mg- a unit of measurement) /3 milliliters (ml - a unit of measurement), 3 ml inhale orally every 6 hours as needed for wheezing (a high-pitched, whistling sound that occurs when air moves through narrowed airways in the lungs) ordered on [DATE REDACTED].

During a concurrent observation and interview on [DATE REDACTED] at 1:05 p.m. with Licensed Vocational Nurse (LVN) 10, Station 4 medication cart was inspected. There was an opened foil pack of Ipratropium-Albuterol Inhalation Solution with no open date. LVN 10 stated the open date should have been written on the foil pack because the medication must be used within 2 weeks after foil envelope was opened per the manufacturer guidelines. LVN 10 stated if there was no open date, the licensed nurse will not know when the medication expires. LVN 10 stated if Resident 28 received expired Ipratropium-Albuterol, there is a risk that the medication's potency (quantity of drug necessary to produce a given effect) will be compromised, and resident will continue to have shortness of breath , SOB, wheezing or other breathing problems.

During a review of the facility's policy and procedure (P&P), titled Medication Storage in the Facility: Storage of Medications, dated Date [DATE REDACTED], The P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0803 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45269

Residents Affected - Few Based on interview and record review, the facility failed to honor food request and food preferences of one of two sampled residents (Resident 76) by ensuring requested food is provided and accommodated.

This failure had the potential to place Resident 76 at risk of not having her nutritional needs met.

Findings:

During a review of Resident 76's Admission Record, the Admission Record indicated the resident was originally admitted on [DATE REDACTED] and was readmitted on [DATE REDACTED] to the facility with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), pulmonary hypertension(a condition where the blood pressure in the lungs is higher than normal).

During a review of Resident 76's Minimum Data Set (MDS- a resident assessment tool) dated 11/20/2024,

the MDS indicated the resident had an intact cognition (thought process) and was dependent (helper does all

the effort) on staff with toileting hygiene, bathing, lower body dressing ( the ability to dress and undress below the waist),and transfer to and from a bed to a chair or wheelchair.

During a review of Resident 76's Order Summary Report dated 11/18/2024, the Order Summary Report indicated an order of No added salt/Controlled carbohydrate diet (CCHO-diet focuses on limiting consumption of foods high in carbohydrates).

During a review of Resident 76's Nutrition Dietary Review dated 3/16/2020, the Nutrition Dietary Review indicated the resident liked brown rice, wheat bread and was on CCHO diet.

During an interview on 2/12/2025, at 3:48 p.m., and subsequent interview on 2/14/2025, at 9:30 a.m. with Resident 76, Resident 76 stated the kitchen always run out of gravy , chicken noodle soup , bacon or cream of wheat. Resident 76 stated the unit with even numbers always get their trays last among the residents and always run of food and given alternative food instead. Resident 76 stated she would get white bread and white cheese bread at times or white cheese and the kitchen was aware of her food preferences because it was on her meal ticket.

During an interview on 2/14/2025, at 9:58 a.m. with Certified Nursing Assistant (CNA 11), CNA11 stated Resident 76 requested 3 cups of cream of wheat but the kitchen ran out yesterday (2/13/2025) and offered

the resident oatmeal. CNA11 stated the resident did not get her cream of wheat yesterday and sometimes

the kitchen ran out of food items that are popular among the residents like bacon or soup.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0803 During an interview on 2/15/2025, at 7:54 a.m. with Dietary Aide (DA 2) , DA 2 stated sometimes the kitchen did not have enough bacon or soup depends on what they have prepared for that meal. DA 2 stated Level of Harm - Minimal harm or residents would get upset and could affect their appetite if they do not receive what they request for a potential for actual harm particular meal. DA 2 stated the residents should get what they want and request.

Residents Affected - Few During an interview on 2/15/2025, at 8:12 a.m. with Assistant Cook, Assistant [NAME] stated if the resident requested for a particular food item and the food was no longer available in the kitchen, the [NAME] could cook some more to accommodate the resident's request even the kitchen had finished preparing and cooking the food for the residents. Assistant [NAME] stated Resident 76 liked raisin toast and bacon. Assistant [NAME] stated that it's true that sometimes the kitchen ran out of cooked food items like potato, bacon, rice because residents requested more of those food items frequently. Assistant [NAME] stated the kitchen should make more food like bacon, cream of wheat and the residents should get their food the way

they like it because they could get sick and lose weight.

During an interview on 2/14/2025, at 4:53 p.m. with Dietary Supervisor (DS), DS stated he does see the residents unless there is a complaint and did not know when was the last time, he saw Resident 76 to see if there is any concern about her food.DS stated it was a miscommunication either from nursing or kitchen staff when Resident 76 did not get what she wanted like bacon or cream of wheat.

During a review of facility's policy and procedure(P&P) titled Food Preferences revised 7/2017, the P& P indicated individual food preferences will be assessed and when possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. The P& P indicated the nursing staff will document resident's food and eating preferences in the care plan and the resident had the right not to comply with therapeutic diets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49889

Residents Affected - Some Based on observation, interview and record review, the facility failed to:

Note: The nursing home is a. Ensure Lysol bleach cleaner was not stored in the dry food storage area. disputing this citation. b. Ensure the drain to the ice machine was free from dirt and debris.

c. Ensure prepared food items in the refrigerator had the prepare date and the use by date.

d. Ensure the freezer temperature logs were completed daily.

These failures have the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Findings:

During a concurrent observation and interview on 2/11/2025, at 8:27 a.m. with the Assistant [NAME] in the dry food storage area, a bottle of Lysol bleach cleaner was observed hanging off of a shelf. The Assistant [NAME] stated Lysol bleach cleaner should not be stored in the dry food storage there could be a chemical spill and leak into the product and could potentially be fatal.

During a concurrent observation and interview on 2/11/2025 at 8:35 a.m. with the Dietary Aide 1 (DA) in the kitchen, DA1 stated that the temperature for the freezer needs to be checked each shift and documented, and the freezer temperature log was missing temperatures. DA1 stated we need to make sure the foods temperature is checked to preserve the freshness and food can spoil if not kept at the correct temperatures, bacteria can grow, and the residents that would eat it could get sick.

During a concurrent observation and interview on 2/11/2025, at 8:42 a.m. with DA 2 in the kitchen. The DA 2 stated the tray of sandwiches and tray of puddings in the refrigerator did not have dates as to when they were prepared or when they should no longer be served to the residents. DA 2 stated residents could get sick if food is served out of date.

During a concurrent observation and interview on 2/14/2025, at 4:39 p.m. with Dietary Supervisor in the kitchen. The DS stated the ice machine drain did have dirt and debris around it, and there is a possibility for bacteria to grow when not kept clean. The DS stated that Lysol bleach cleaner should not have been left in

the dry food storage area. DS stated that it is a chemical hazard if a resident ingested it and it is poisonous.

The DS stated everything needs to be labeled and dated before it goes in the refrigerator, we need to ensure

the food is not out of date and can be served safely. DS stated there is a potential for gastro intestinal ( GI-relating to the stomach and the intestines) issues if food is served out of date. DS stated freezer temperature's need to be checked and documented every shift to ensure food is kept at a temperature below zero, there is a potential for GI issues if food is not stored at the right temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0812 During an interview on 2/15/2025, at 7:31 a.m. with the Administrator (ADM), the ADM stated chemicals should not be left in food storage areas, there is a potential for an adverse reaction. The ADM stated the ice Level of Harm - Minimal harm or machine drain should not have dirt or debris, there should be proper sanitation done for infection control. The potential for actual harm ADM stated food needs to be properly label with open dates and use by dates, staff would not know when

the food is out of date and there could be a possible adverse reaction for the residents if served out of date Residents Affected - Some food. The ADM stated food can spoil when not kept at the proper temperature that's why temperature logs need to be kept up to date. Note: The nursing home is disputing this citation. During a review of the facility's policy and procedure (P&P) titled Food Receiving and Storage, dated 10/2017, the P&P indicated foods shall be received and stored in a manner that complies with safe food handling. All food stored in the refrigerator or freezer will be covered labeled and dated (use-by date). Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition service manager or designee and documented according to state-specific requirements.

During a review of the facility's policy and procedure (P&P) titled Sanitization, dated 10/2017, the P&P indicated the food service area shall be maintained in a clean and sanitary manner. All kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufactures instructions and facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 49862

Residents Affected - Few Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to establish a system for:

1. Medication Management and safety by reducing medication errors and ensure accurate medication administration to enhance resident safety.

2. Falls and fall -related injuries by minimizing the occurrence of falls among residents and reduce the severity of fall-related injuries.

3. Pressure ulcers monitoring for residents who are at risk for developing or acquiring pressure ulcers.

These deficient practices resulted for residents not receiving medically related necessary care, resulting in medication errors, injury related to falls, lack of monitoring and document pressures injuries.

Findings:

During an interview on 02/15/2025 at 7:51 p.m. with the Administrator (ADM), the ADM stated all what they are working, but cannot proved how to prevent highest medication errors rate, how to present fall and injury, and how to over and present pressure injury. There were no safety measures in place to prevent other residents' meds errors and monitory.

During a review of the facility's policy and procedure (P/P) titled, Quality Assurance and Performance Improvement (QAPI) Plan, revised 01/2025, indicated the facility to establish and maintain an ongoing, systematic and proactive facility-wide process and data driven information to plan to measure and assess as well as to carry out the plan and improve resident care, outcomes and safety based on its mission, strategic goals and objectives.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45269 potential for actual harm 49145 Residents Affected - Some 49862

Based on observation, interview, and record review, the facility failed to observe infection control practices by failing to:

1.Ensure oxygen tubing and bags were changed and labeled weekly for Residents 126 and 500.

2.Ensure tube feeding and water bags were changed and labeled for Resident 218.

3.Ensure the licensed nurse removed her personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments.) when exiting Resident 517's room and prior to walking out into the hallway.

4.Ensure the Certified Nursing Assistant (CNA) will call housekeeping to properly clean the floor in Resident 106's room after feces are found scattered in the floor.

5.Ensure a visitor was educated and informed about the use of PPE) was worn when entering Resident 169's room who had Candida Auris(C. Auris- a yeast that can cause severe infections, including bloodstream infections and often resistant to antifungal medications , difficult to treat and spreads easily through contaminated surfaces or medical equipment) and on Contact Isolation(steps that facility's visitors and staff follow to help stop spreading germs that can be spread by touching the resident or surfaces in the room).

These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.

Findings:

During a review of Resident 126's Admission Record, the Admission Record indicated Resident 126 was admitted to the facility on [DATE REDACTED], readmitted on [DATE REDACTED] with diagnoses including myocardial infarction ({MI}- heart attack) and chronic obstructive pulmonary disease ({COPD}- a chronic lung disease causing a difficulty

in breathing).

During a review of Resident 126's Minimum Data Set ({MDS}- a resident assessment tool) dated 11/25/2024,

the MDS indicated Resident 126's cognition (ability to think, understand, learn, and remember) is intact. The MDS indicated Resident 126 required substantial/maximal assistance (helper does more than half the effort) with toileting, showering/bathing, and dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0880 During a review of Resident 500's Admission Record, the Admission Record indicated Resident 500 was admitted to the facility on [DATE REDACTED] with diagnoses including congestive heart failure ({CHF}- a heart disorder Level of Harm - Minimal harm or which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and atrial potential for actual harm fibrillation (an irregular and often very rapid heart rhythm).

Residents Affected - Some During a review of Resident 500's MDS dated [DATE REDACTED], the MDS indicated Resident 500's cognition is intact.

The MDS indicated Resident 500 required substantial/maximal assistance with toileting, showering/bathing, and dressing.

During a review of Resident 218's Admission Record, the Admission Record indicated Resident 218 was admitted to the facility on [DATE REDACTED] with diagnoses including cerebral infarction (blood flow to the brain is blocked) and dysphagia (difficulty swallowing).

During a review of Resident 218's MDS dated [DATE REDACTED], the MDS indicated Resident 218's cognition was moderately impaired. The MDS indicated Resident 218 was dependent (helper does all the effort) with personal hygiene, toileting, showering/bathing, and dressing.

During a review of Resident 517's Admission Record, the Admission Record indicated Resident 517 was admitted to the facility on [DATE REDACTED] with diagnoses of diabetes mellitus ({DM}- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension ({HTN}- high blood pressure).

During a review of Resident 517's MDS dated [DATE REDACTED], the MDS indicated Resident 218's cognition is intact.

During a review of 517's Change in Condition (COC) dated 2/10/2025, the COC indicated Resident 517 tested positive for Covid (a highly contagious respiratory disease).

During a concurrent observation and interview on 2/11/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 8, LVN 8, confirmed Resident 126 and 500's oxygen tubing and bag were not dated so she is not sure if or when they were changed. LVN 8 stated the oxygen tubing and bag is supposed to be changed once a week and labeled with the residents name and the date for infection control purposes to ensure bacteria does not grow in the tubing which could potentially cause a respiratory infection, pneumonia, or irritation around the nasal area.

During a continued concurrent observation and interview on 2/11/2025 at 11:19 a.m. with LVN 8, LVN 8 stated Resident 218's tube feeding, and water bag was not labeled or dated. LVN 8 stated the tube feeding and water bags are supposed to be changed every 24 hours. LVN 8 stated its important to change and date every 24 hours for infection control because if not it can potentially cause stomach issues if the feeding spoils from not being changed.

During a concurrent observation and interview on 2/11/2025 at 3:09 p.m. with the Registered Nurse (RN) 3, RN 3 was observed coming out of Resident 517's room into the hallway still wearing her PPE. RN 3 stated

she made a mistake and should have removed her PPE prior to exiting the resident's room because the PPE is contaminated, and it could potentially contaminate others and spread the infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0880 During an interview on 2/15/2025 at 4:54 p.m. with the Director of Quality Assurance (QA), the QA stated its important to change and label oxygen tubing and tube feeding bags to prevent the spread of infection. Stated Level of Harm - Minimal harm or if the tubing's are not changed when they are supposed to be changed, it can potentially place the residents potential for actual harm at risk for infection. The QA stated PPE should be removed before leaving a residents room because if they do not, it can lead to a break in infection control placing the residents and staff at risk for infection. Residents Affected - Some

During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, Delivery Device, dated 1/2025, the P&P indicated, Plastic bags are replaced weekly and as needed. Label the delivery device tubing at the point that it attaches to the humidifier or nipple adapter with the date. Delivery devices are to be changed/replaced according to specific policy.

During a review of the facility's P&P titled, Enteral Feedings- Safety Precautions, dated 12/2018, the P&P indicated, Change administration sets for open-system enteral feedings and water flush bag sets at least every 24 hours.

During a review of the facility's P&P titled, Standard Precautions, dated 2/2025, the P&P indicated, Before leaving the resident's room or cubicle, remove and discard PPE.

4.During a review of Resident 106's Admission Record, the Admission Record indicated was originally admitted on [DATE REDACTED] and was readmitted on [DATE REDACTED] to the facility with diagnoses that included dementia(a progressive state of decline in mental abilities), unspecified psychosis(a severe mental condition in which thought, and emotions are so affected that contact is lost with realty), and heart failure( condition where the heart muscle becomes weakened or stiff making it difficult to pump blood effectively).

During a review of Resident 106's History and Physical (H&P) dated 1/7/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident MDS dated [DATE REDACTED], the MDS indicated the resident had severe cognitive impairment( a serious decline in mental function that makes it hard to think, learn, and function independently)and was dependent on staff with bathing/showering. The MDS indicated the resident required supervision or touching assistance with dressing and toileting hygiene.

During a concurrent observation and interview on 2/12/2025, at 10:18 a.m. in Resident 106's room and subsequent interview on 2/14/2025, at 9:07 a.m. with Certified Nursing Assistant (CNA 4), CNA 4 was providing care for Resident 106. Observed small areas of feces were scattered in the floor. CNA 4 stated Resident 106 had a bowel movement and some of the feces had probably fallen off the floor when the resident came from the shower room. Observed CNA4 wiped off the floor with dry towels where areas of feces are found. CNA4 stated she would come back to the room to disinfect and make Resident 106's bed. Observed CNA 4 walked out of the room and carried some clean linens back to the resident's room. She stated she forgot to call the housekeeping because her mind was blank at that time. CNA 4 stated she should have put a sign and call housekeeping to properly clean the dirty floor to prevent spread of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0880 During an interview on 2/12/2025, at 10:23 a.m. with Licensed Vocational Nurse (LVN 14), LVN 14 stated the staff should wipe off the feces with dry towel, call housekeeping right away , and place a sign to ensure Level of Harm - Minimal harm or people would not be stepping on the dirty floor to prevent contamination and spread of infection. potential for actual harm

During an interview on 2/15/2025, at 7:24 p.m. with Chief Clinical Officer (CCO), CCO stated feces on the Residents Affected - Some floor should be cleaned immediately, put the precaution cone and call housekeeping to clean and disinfect

the floor to prevent break in infection control and spread of infection.

5. During a review of Resident 169's Admission Record, the Admission Record indicated the resident was originally admitted on [DATE REDACTED] and was readmitted on [DATE REDACTED] to the facility with diagnoses that included unspecified candidiasis( infection caused by an overgrowth of a type of yeast in the body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and pressure induced deep tissue damage of sacral region(prolonged pressure applied to the lower back that caused damage to the underlying soft tissues, muscles, fat due to restricted blood flow).

During a review of Resident 169's MDS dated [DATE REDACTED], the MDS indicated the resident had moderately impaired cognitive skills and required partial/ moderate assistance with bed mobility. The MDS indicated the resident required substantial/ maximal assistance with toileting hygiene, bathing, and dressing.

During a review of Resident 169's Order Summary Report dated 11/30/2024, the Order Summary Report indicated an order for Contact Isolation for Candida Auris.

During a review of Resident 169's Care Plan initiated on 9/24/2024, the Care Plan indicated Resident 169 had a multi-drug-resistant organism(microorganisms, predominantly bacteria that are resistant to a lot of antibiotics or antifungals) called C. Auris. The Care plan goal indicated the resident will respond to treatment through the review date. The Care Plan interventions included instructing visitors / family/caregivers to wear disposable gown and gloves when in resident's room and to wash hands before leaving room.

During a review of Resident 169's Candida Auris Surveillance NAA W reflex fungal culture ( test to detect presence of Candida Auris) dated 9/17/2024, the Candida Auris Surveillance indicated C. Auris was detected.

During an observation on 2/14/2025, at 2:58 p.m. in Resident 169's room, a signage for Contact Isolation was posted and an isolation cart ( medical cart that holds PPE and supplies for patients with infectious diseases)was visible near the entryway of the door. Observed a visitor wearing a surgical mask and not wearing a PPE was sitting next to the resident's bed.

During a concurrent observation and interview on 2/14/2025, at 3:01 p.m. with LVN 12, LVN 12 stated the visitor inside Resident 169's room was a family member (FM) and should be wearing a PPE when visiting. LVN 12 stated the resident was in contact isolation because of C. Auris. LVN 12 stated the visitor might have forgotten to wear PPE and will inform her on what precautions to observe when visiting the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0880 During an interview on 2/15/2025, at 1:54 p.m. with CNA 5, CNA5 stated Resident 169 is on contact isolation and everything the resident had touched could carry the germs. CNA5 stated she performed hand hygiene, Level of Harm - Minimal harm or wear gown, gloves, mask and practice hand hygiene before and after entering the room. CNA5 stated potential for actual harm infection could be spread to other residents, staff and visitors if contact isolation is not observed when entering Resident 169's room. Residents Affected - Some

During an interview on 2/14/2025, at 4:38 p.m. and subsequent interview on 2/15/2025, at 5:10 p.m. with Director of Quality Assurance (DQA), DQA stated contact isolation should be observed in resident who had C. Auris. DQA stated the visitor should have worn gown, gloves, mask and practiced hand hygiene before and after visiting. DQA stated the staff is responsible in providing education to visitors about isolation precautions and infection control prevention. DQA stated a break in infection control could occur and could place residents, visitors and staff at risk for infection if contact isolation is not observed.

During an interview on 2/5/2025, at 7:24 p.m. with Director of Nursing (DON), DON stated the licensed nurses should provide education about contact isolation for C. Auris to the visitors for everyone's protection and prevention of spread of infection to the staff, visitors and other residents.

During a review of facility's P&P titled Candida Auris updated 9/11/2024, the P&P indicated C. Auris spreads easily and can cause life-threatening infections in some patients. The P&P indicated patients who are colonized (person has the yeast in their body but not sick) can spread C. Auris the same ways that patients who are infected can and patients can remain colonized for several weeks, months or longer even if they never had symptoms.

During a review of facility's P&P titled Transmission Based Precautions revised 6/2024, the P&P indicated contact precautions are used for residents with known or suspected infections that represent an increased risk for contact transmission. The P&P indicated using PPE, including gloves and gowns and should be used for all interactions that may involve contact with the resident or the resident's environment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50144 potential for actual harm Based on interview and record review, the facility failed to implement the antibiotic stewardship program Residents Affected - Few policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for two of three sampled residents (Resident 98) receiving ampicillin (antibiotic used to treat bacterial infections).

This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification.

Findings:

During a review of Resident 98's Admission Record, the Admission record indicated Resident 98 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis

on one side of the body) following unspecified cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side and neuromuscular dysfunction of bladder (condition where

the nerves controlling bladder function are damaged, leading to impaired bladder muscle coordination resulting in difficulty urinating or incontinence).

During a review of Resident 98's Minimum Data Set (MDS-a resident assessment tool) dated 11/18/2024,

the MDS indicated Resident 98's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired, required supervision for eating and oral hygiene, required maximal assistance (helper does more than half the effort) for dressing and showering, and was dependent (required complete assistance of 2 or more helpers) for toileting.

During a review of Resident 98's physician order summary printed on 2/15/2025, the order indicated Ampicillin Sodium Injection Solution Reconstituted 1 Gram (GM - a unit of measurement) Use 1 gram intravenously every 6 hours for urinary tract infection (UTI- an infection in the bladder/urinary tract) for 5 days.

During a concurrent interview and record review on 2/14/20 at 2:50 p.m. with the Director of Quality Assurance (QA), Resident 98's Infection Screening Evaluation, dated 1/31/2025). Resident 98's Infection Screening Evaluation indicated, No IPC Case Triggered. The QA stated Resident 98's symptoms did not meet criteria, and there is no documentation indicating the physician was notified. The QA stated the physician should be notified if a resident does not meet Loeb's or Mcgeer's criteria to see if medication needs to be reevaluated.

During an interview on 2/15/2025 at 7:24 p.m. with the Chief Clinical Officer (CCO), the CCO stated if the resident does not meet Mcgeer's criteria, there can be a negative outcome for the resident. The CCO stated

the resident can be at risk for multidrug resistant organisms or antibiotics unnecessarily or without justification.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0881 During a review of the facility's policy and procedure (P&P), titled Infection and Control Program dated October August 2023, P&P indicated, the antibiotic usage is evaluated and practitioners are provided Level of Harm - Minimal harm or feedback on review. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50144 potential for actual harm Based on observation, interview and record review, the facility failed to offer, educate, and track influenza Residents Affected - Few vaccinations for residents per facility's policy for one or five sampled residents (Resident 218).

This failure had the potential to place all residents at risk for infection of influenza.

Findings:

During a review of Resident 218's Admission record , the Admission Record indicated Resident 218 was admitted to the facility on [DATE REDACTED] with a diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side.

During a review of Resident 218's Minimum Data Set (MDS - a resident assessment tool), dated 12/20/2024,

the MDS indicated Resident 218's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired and was dependent for hygiene, bathing, and dressing.

During a concurrent interview and record review on 2/14/20 at 2:18 p.m. with the Director of Quality Assurance (QA), Resident 218's Immunization History Reports. The QA stated Resident 218 was eligible for

the 2024-2025 influenza vaccine, and did not have documentation indicating that the 2024-2025 influenza vaccine was offered, education was provided, or that Resident 218 declined the vaccine. The QA stated it is important to offer all vaccinations to all eligible residents to prevent the spread of infection.

During an interview on 2/15/2025 at 7:24 p.m. with the Chief Clinical Officer (CCO), the CCO stated it is important for residents to be offered the influenza vaccine to protect residents, lessen the severity of illness, and prevent potential outbreaks.

During a review of the facility's policy and procedure (P&P), titled Influenza Vaccine, revised October 2019,

the P&P indicated:

a. All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associate with vaccinations against influenza.

b. Prior to the vaccination the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine.

c. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0883 d. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the residence medical record. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50144

Residents Affected - Few Based on observation, interview and record review, the facility failed to offer, educate, and track coronavirus vaccinations for residents per facility's policy for two or five sampled residents (Resident 218 and Resident 121).

This failure had the potential to place all residents at risk for infection of coronavirus.

Findings:

A. During a review of Resident 218's Admission record, the Admission record indicated Resident 218 was admitted to the facility on [DATE REDACTED] with a diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side.

During a review of Resident 218's Minimum Data Set (MDS - a resident assessment tool), dated 12/20/2024,

the MDS indicated Resident 218's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired and was dependent for hygiene, bathing, and dressing.

B. During a review of Resident 121's Admission record, the Admission record indicated Resident 121 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including chronic respiratory failure and dependence on respirator (ventilator- a medical device to help support or replace breathing).

During a review of Resident 121's MDS, dated [DATE REDACTED], the MDS indicated Resident 121's cognition was severely and was dependent for hygiene, bathing, and dressing.

During a concurrent interview and record review on 2/14/20 at 2:18 p.m. with the Director of Quality Assurance (QA), Resident 218 and Resident 121's Immunization History Reports:

A. The QA stated Resident 218 was eligible for the 2024-2025 coronavirus vaccine, and did not have documentation indicating that the 2024-2025 coronavirus vaccine was offered, education was provided, or that Resident 218 declined the vaccine.

B. The QA stated Resident 121 was eligible for the 2024-2025 coronavirus vaccine, and did not have documentation indicating that the 2024-2025 coronavirus vaccine was offered, education was provided, or that Resident 121 declined the vaccine. The QA stated it is important to offer all vaccinations to all eligible residents to prevent the spread of infection.

During an interview on 2/15/2025 at 7:24 p.m. with the Chief Clinical Officer (CCO), the CCO stated it is important for residents to be offered the coronavirus vaccine to protect residents, lessen the severity of illness, and prevent potential outbreaks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0887 During a review of the facility's policy and procedure (P&P), titled Covid-19 Policy, revised October 2024, the P&P indicated it is the policy of this facility to maintain a safe environment by encouraging and supporting Level of Harm - Minimal harm or COVID19 vaccination for eligible residents and healthcare personnel. potential for actual harm

During a review of the facility's policy and procedure (P&P), titled Vaccination of Residents, revised October Residents Affected - Few 2019, the P&P indicated:

a.All residents will be offered vaccines that aid in preventing infectious disease unless the vaccine is medically contraindicated of the resident has already been vaccinate.

b.Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations.

c.Provision of such education shall be documented in the resident's medical record.

d.If vaccines are refused, the refusal shall be documented in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 54 056488 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056488 B. Wing 02/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center 22617 So. Vermont Ave Torrance, CA 90502

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 49862

Residents Affected - Some Based on observation, interview, and record review, the facility failed to accommodate no more than four residents, by failing to ensure rooms provide at least 80 square feet ([sq. ft.] unit of measurement) per resident in multiple resident bedrooms. The insufficient space could lead to inadequate nursing care to the residents.

This failure had the potential to decrease the resident's privacy, quality of care and quality of life.

Findings:

During a review of the facility's Client Accommodations Analysis Form (CAAF) completed by the facility on 02/15/25, the facility had 83 rooms that measured less than 80 sq. ft. per resident in multi-bedrooms. The CAAF indicated rooms:

105, 107, 109 , 111,113,115,117,119,121,123,125,127,201,202, 203,205,206, 207, 208, 209, 210,211,212, 214,216,218, 220, 301,302,303,304,305,306,307,308,309,310,311, 312,401,402,403,404,405,407,408,409, 410,411,412,413,414,415,416,417,418, 419,421,501,502,503,504,505,506,507,508,509,510,511,512,513, 514,515,516,517,518,519, 520, 521, 522, 523, 525, and 527 are less than 80 square feet to accommodate residents in each room.

During an observation made to the requested rooms during the annual recertification survey at the facility from 02/11/2025 to 02/15/25 indicated no concerns or problems with privacy, safety, and residents' care.

During an interview on 02/15/25 at 3:42 p.m. with the Administrator (ADM), ADM stated residents' care was not affected and no one was complaining that their room is crowded or affected their mobility and safety. The ADM stated the facility will be requesting a room waiver.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 54 056488