Sunnyside Nursing Center

F 0558

facility shall provide each resident the care in a manner that promotes and enhances quality of life, dignity, respect, and individuality while honoring resident rights and preferences.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center

22617 S. 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interventions. During a review of the facility's P/P titled, Falling Star Program updated 4/11/2016, P/P indicated the Falling Star Program is a facility-wide effort to reduce the incidence of falls among residents through increasing staff awareness of residents high risk for fall. The P/P indicated the facility assesses the resident for fall risk upon admission, quarterly and when a significant change of condition occurs and a plan of care is developed based on this assessment. The P/P indicated a resident found to be at risk for falls or repeated falls as per Interdisciplinary Team Assessment will be placed on the Falling Star Program and if

the resident is appropriate for Falling Star Program, the care plan will be updated with the following interventions but not limited to:a. low bedb. landing padc. colored wrist band; and ad. star magnet by the door of the resident room.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center

22617 S. 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

on [DATE REDACTED] at 1 p.m., the facility's Pharmacist stated Baclofen causes central nervous system depression (a condition when the brain and the spinal cord slow down, and the body cannot function properly), dizziness and confusion. The Pharmacist stated physicians should be aware of the side effects of this medication and adjust the dose and/or stop the medication based on the residents' kidney function, response and/or tolerance to the medication. The Pharmacist stated Baclofen cannot be excreted (eliminate or discharge wastes from the body) well from the body when the kidneys are impaired and could increase a resident's risk of side effects associated with the use of the medication. During a telephone interview on [DATE REDACTED] at 2:51 p.m., the on-call physician, who covered for Resident 10's attending physician, stated the admitting nurse should have contacted the Resident's attending physician to discuss the residents' discharge summary and discharge medications to identify and/or resolve any inconsistencies and discrepancies.

During a telephone interview on [DATE REDACTED] at 4:28 p.m., the GACH's Nephrologist stated Baclofen was not nephrotoxic (poisonous to the kidneys), but it could accumulate in the blood when the kidneys were impaired and cause a resident to have an altered level of consciousness ([ALOC] a change in a patient's state of awareness [ability to relate to self and the environment] and arousal [alertness]) During a telephone

interview on [DATE REDACTED] at 1:20 p.m., the facility's Medical Director stated it was the facility's policy and common practice for the doctors and the licensed nurses to conduct a thorough reconciliation of the residents' discharge medications and review of discharge instructions including the discharge summary to clarify and/or decide the residents' treatment and medications. The Medical Director stated licensed nurses were not to transcribe any medication order without the approval of the primary care physician to ensure the residents were free from inappropriate medications that could affect their safety and wellbeing. During an

interview on [DATE REDACTED] at 11 a.m., the CCO stated Resident 10's COC and the life threatening complications could have been prevented if the admission process was followed. During an interview on [DATE REDACTED] at 12:33 p.m., the Administrator (ADM) stated the failure to reconcile the medications with Resident 10's physician should not have happened because the facility has ongoing policies and procedures related to admission medication reconciliation. According to Mayo Clinic (a non-profit medical group practice that provides comprehensive and integrated healthcare services renowned for its expertise in cardiology, cancer care, neurology, orthopedics and transplant medicine), BACLOFEN (Oral Route)- Side effects and Dosage dated [DATE REDACTED], Baclofen was used to help relax the muscles to relieve spasms and cramping by acting on the central nervous system to produce muscle relaxant effects. This medication must be prescribed and used with caution if anyone has an allergy or unusual reaction to it and limit use in elderly because of age-related kidney, liver or heart problems that may likely cause side effects of hallucination, confusion, mental depression, and severe drowsiness. The presence of a medical problem such as a kidney disease may increase the effects of the medication because of slower removal of medicine form the body and should be avoided because of increased risk of serious brain problems such as encephalopathy (a medical condition of the brain affected by some agent or condition such as toxins in the blood). https://www.mayoclinic.org

During a review of the facility's P/P titled, Medication Orders Non Controlled Medication Order Documentation revised 8/2019, the P/P indicated the written transfer orders (sent with a resident by a hospital or other healthcare facility) shall be verified with the current order attending physician before medications are administered and the nurse who transcribes the orders must document in the admission form the date, time and by whom the orders were noted.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunnyside Nursing Center

22617 S. 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and there was no QAPI meeting conducted after the facility identified the deficient practice related to Resident 10's medication error. During a review of the facility's Policy and Procedure (P/P) titled, Quality Assurance Performance Improvement revised 11/9/2021, the P/P indicated . the facility should ensure the correction of quality deficiencies components to include: a. Tracking and measure performance b.

Establishing goals and thresholds for performance measurement c. Systematically analyzing the underlying causes of systemic quality deficiencies d. Developing and implementing corrective action or performance improvement activities to include methods to validate and update the staff competencies at the time of hire and periodically or as needed; and e. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Event ID:

Facility ID:

If continuation sheet