Health inspection·July 9, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 2) who was incontinent (involuntary voiding of urine and stool) of bowel (stool) and bladder (urine), and had a urinary tract infection (UTI- an infection in the bladder/urinary tract) perineal care (the cleaning and maintenance of the area between the anus and genitals, which is essential for maintaining good hygiene, preventing infections, and promoting overall health and well-being) was properly provided for one of three sampled residents (Resident 2).This failure had the potential for Resident 2 to have an exacerbation (the worsening of a disease, symptom, or problem) of her current UTI which could result in unnecessary hospitalization and sepsis (a life-threatening blood infection). Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including gout (a form of inflammatory arthritis that develops in some people who have high levels of uric acid in the blood), bacterial pneumonia (an infection/inflammation in the lungs), and generalized muscle weakness.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 5/1/2025, the MDS indicated Resident 2's cognition was intact and was dependent (helper does all the effort) on nursing staff for toileting hygiene, showering/bathing, dressing the lower body, and personal hygiene. During a review of Resident 2's Clinical Record (Care Plan section), dated 2/8/2024, the Care Plan indicated Resident 2 was incontinent of bowel and bladder. Under this Care Plan, the goals indicated Resident 2's risk of complications from incontinence will be minimized daily. The Care Plan's interventions included cleaning the peri-area ([perineum] the region of the body between the anus and the external genitals) and providing absorbent incontinence briefs with each incontinence episode due to Resident 2 being dependent on staff for incontinence care.During a review of Resident 2's Microbiology Urine Report (Lab Results) dated 3/9/2025 and timed at 10:32 a.m., the Microbiology Urine Report indicated Resident 2 was positive for Escherichia coli (E. coli-bacterium that typically resides in the intestines of humans and animals) in the urine.During a review of Resident 2's Physician's Orders, dated 3/10/2025, the Physician's Orders indicated Resident 2 was to receive Cephalexin (an antibiotic used to treat bacterial infection) oral tablet, 500 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) twice a day for UTI therapy.During a review of Resident 2's Microbiology Urine Report dated 5/1/2025 and timed at 3:40 p.m., the Microbiology Urine Report indicated Resident 2 was positive for E. coli, and Enterococcus (bacterium that are commonly found in the intestines of humans and animals) in the urine.During a review of Resident 2's Physician's Orders, dated 5/2/2025, the Physician's Orders indicated Resident 2 was to receive Macrobid (an antibiotic used to treat and prevent UTIs) oral capsule 100 mg one time a day for UTI therapy.During a review of Resident 2's Grievance Form, dated 5/5/2025, the Grievance Form indicated Family Member (FM) 1 Page 1 of 3 056488 056488 07/09/2025 Sunnyside Nursing Center 22617 S. Vermont Ave Torrance, CA 90502

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was concerned about Resident 2 having pain upon urination and had to wait two hours to be changed after informing nursing staff.During a review of Resident 2's Urine Culture Report (Lab Results) dated 5/10/2025 and timed at 9:56 a.m., the Urine Culture Report indicated Resident 2 was positive for Enterococcus in the urine.During a review of Resident 2's Physician's Orders, dated 5/12/2025, the Physician's Orders indicated Resident 2 was to receive Macrobid oral capsule 100 mg one time a day for UTI therapy.During a review of Resident 2's Physician's Orders, dated 5/15/2025, the Physician's Orders indicated Resident 2 was to receive Nitrofurantoin Macrocrystal (an antibiotic used to treat and prevent lower UTIs) oral capsule 50 mg one time a day for UTI therapy.During a review of Resident 2's Grievance Form, dated 6/17/2025, the Grievance Form indicated FM 1 had a concern on two occasions from 6/13/2025 through 6/15/2025, where Resident 2 had to wait two hours to be cleaned after having a bowel movement to be cleaned. The Grievance Form indicated FM 1 was concerned for Resident 2 getting UTIs. The Grievance Form follow up action indicated the facility implemented intervention of checking Resident 2 once every two hours and changing Resident 2 as needed by reevaluating and restructuring the nursing assignment.During a concurrent observation and interview on 7/8/2025 at 6:19 a.m., Resident 2 was awake, alert, lying in bed, supine (on back) with the head of the bed at 45 degrees. Resident 2 stated she was changed by nursing five minutes prior (6:14 a.m.).During a concurrent observation and interview on 7/8/2025 at 8:34 a.m., Resident 2 was noted to still be lying in bed, supine with the head of the bed at 45 degrees. Resident 2 stated she had a bowel movement and needed to be changed but nobody had come to check on her yet to see if she needed to be changed.During an observation on 7/8/2025 at 8:52 a.m., Certified Nursing Assistant (CNA) 1 began to change Resident 2's soiled incontinence brief. CNA 1 started by cleaning Resident 2's frontal area, using soap and water on the labia majora and inguinal folds. CNA 1 then turned Resident 2 to her right side and began to clean the bowel movement from her outer/inner buttocks and lower back. CNA 1 then removed a pair of contaminated gloves and had another pair of glove's underneath. CNA 1 then rolled/stuffed the clean incontinence brief under Resident 2 and turned her to her left side to adjust it to be aligned properly. CNA 1 then placed Resident 2 back on her back and began cleaning Resident 2's frontal area again without performing hand hygiene and wearing clean gloves. CNA 1 never cleaned inside Resident 2's labia. Resident 2 stated to CNA 1 that she had pain in her urethra (the tube that carries urine from the bladder out of the body), and CNA 1 began to ask questions about the pain. CNA 1 then sealed Resident 2's incontinence brief.During an interview on 7/8/2025 at 9:43 a.m., CNA 1 stated she did not know it was not ok to double glove and stated she should have cleaned Resident 2 more thoroughly since females need to be cleaned on the inside of their lady parts as well. CNA 1 stated that was how she was trained by other CNAs here at the facility.During an interview on 7/8/2025 at 1:49 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 2 needed to be cleaned every two hours or more as needed to prevent UTIs. LVN 1 stated Resident 2 was able to let nursing staff know when she needed to be changed but has had a UTI at least 5 times because someone is not changing her correctly and frequently enough. LVN 1 stated a lot of times she had noticed that she was soaked in the morning with enough urine to seep through the incontinence brief and believed night shift was not changing residents enough.During an interview on 7/9/2025 at 10:52 a.m., the Director of Staff Development (DSD) stated when cleaning a female resident, the CNA had to open the labia and clean the inside, and not just on the outside of the labia because it harbors bacteria. The DSD stated double gloving is not the standard of practice, and after coming into contact with feces, hand hygiene should be performed, and a new pair of gloves should be put on if further cleaning is required, such as needing to clean the frontal area again. During an interview on 7/9/2025, at 2:13 p.m., the Chief Clinical Officer 056488 Page 2 of 3 056488 07/09/2025 Sunnyside Nursing Center 22617 S. Vermont Ave Torrance, CA 90502

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she was aware that Resident 2 had frequent UTIs and per their policy CNAs should clean in-between the folds, rinse thoroughly, and make sure skin is dry. The CCO stated if CNAs clean a dirty area, then a clean area without hand hygiene and changing gloves that could potentially cause Resident 2 to have contracted her UTIs.During a review of the facility's undated UTI Prevention Lesson Plan, the Lesson Plan indicated prompt changing is essential to help prevent UTI which can occur when bacteria enter the urinary tract, often due to prolonged exposure to moisture and bacteria. The Lesson Plan indicated that residents at high risk for UTIs include those who are incontinent and left in soiled briefs for extended periods and limited mobility who cannot clean themselves properly. The Lesson Plan indicated females are more prone to UTIs and proper perineal (perineum) care for females includes wiping front to back to prevent fecal bacterial from entering the urinary tract. The Lesson Plan indicated best practice is to change residents immediately when soiled or wet, and to always wear gloves and follow proper infection control protocols. During a review of the facility's policy and procedure (P&P) titled, Incontinence Care, dated 10/2024, the P&P indicated the purpose of the policy was to promote skin hygiene, minimize the risk of infection, and facility skin integrity by providing incontinent care as needed to residents. The P&P indicated to wash skin areas and dry very well, especially in the skin folds.During a review of the facility's P&P titled, Routine Resident Care, dated 10/2024, the P&P indicated the purpose of the policy was for residents to receive the necessary assistance to maintain good grooming and personal/oral hygiene. The P&P indicated incontinence care should be provided timely according to each resident's needs.During a review of the facility's P&P titled, Hand Hygiene, dated 2/2025, the P&P indicated the purpose of the policy was to reduce the risk of infection transmission and protect residents. The P&P indicated hand hygiene must be performed after contact with bodily fluids. The P&P indicated gloves do not replace hand hygiene and must be performed before donning (putting on) gloves and immediately after. The P&P indicated to change gloves between tasks.During a review of the facility's P&P titled Standard Precautions, dated 2/2025, the P&P indicated the purpose of the policy was to implement infection control guidelines to prevent the spread of infectious agents. The P&P indicated to change gloves during resident care if the hand will move from a contaminated body-site to a clean body-site. 056488 Page 3 of 3