Health inspection·September 10, 2025

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: 056488 If continuation sheet Page 2 of 11 Printed: 05/15/2026 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 056488 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan was created to include a Fall Management Program for one of two sampled residents (Resident 16), who was assessed at high risk for falls, per the facility's policy and procedure (P/P). This deficient practice resulted in the care needs for Resident 16 not being thoroughly addressed and placed Resident 16 at risk for falls and injuries. Findings: During a review of Resident 16's admission Record (Face Sheet), the Face Sheet indicated Resident 9 was admitted to the facility on [DATE] with diagnosis including cerebral infarction ([stroke] loss of blood flow to a part of the brain) with left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 16's Minimum Data Set ([MDS] a resident assessment tool) dated 8/4/2025, the MDS indicated Resident 16 was able to make decisions that were reasonable and consistent and she required a one person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) During a review of Resident 16's Nursing Morse Fall Scale dated 7/28/2025 and timed at 6 p.m., the Nursing Morse Fall Scale indicated Resident 16's Fall Risk Score was 65 (45 and higher score indicated a high risk for falls). The Nursing Morse Fall Scale indicated Resident 16 overestimated or forget her limits, was weak, had multiple medical diagnosis, and had a history of falls. During a review of Resident 16's Interdisciplinary Team Conference ([IDT] a group of healthcare professionals from different disciplines who work together to plan, coordinate and deliver comprehensive person-centered care to a resident) Record dated 8/4/2025 and timed at 8:19 a.m., the IDT Team Conference Record indicated Resident 16 was a high risk for falls due to weakness on the left side of her body, she was unable to care for herself and needed services to assist with her current condition and other chronic illnesses. During a review of Resident 16's untitled Care Plan, dated 7/28/2025, the Care Plan indicated Resident 16 had an increased risk of falls. The Care Plan's goal was for Resident 16 to understand the importance of seeking assistance to help reduce the risk of falls. The Care Plan's interventions included attempting to anticipate and meet Resident 16's needs and to encourage Resident 16 to use the call light for assistance. Continued review of the Care Plan indicated there was no documentation to indicate a Fall Management Program was included. During an interview on 9/5/2025 at 11:10 a.m., the Senior Nurse executive (SNE) stated, Resident 16 was identified as a high risk for falls upon admission, and the Falling Star Program should have been incorporated in her Care Plan, which included a low bed, fall pad, placing a star on her door, head of the bed and armband. During an interview on 9/10/2025 at 11:08 a.m., the Chief Clinical Officer (CCO) stated it was the responsibility of the IDT to create a comprehensive care plan for residents' at high risk for falls and to ensure the facility's Fall Management Program was included as part of the interventions to minimize, if not prevent, a fall and/or an injury. During a review of the facility's P/P titled, Care Plans-Comprehensive Person Centered revised 10/2/2024, the P/P indicated the Interdisciplinary Team of the facility shall manage and assist in formulating and implementing the residents' comprehensive person-centered care plan to ensure the objectives and timetables are measurable in order to meet the residents' physical, psychological and functional needs. During a review of the facility's undated, P/P titled, Risk Score Fall Prevention Protocol the P/P indicated the Morse Fall Scale was implemented by the facility to guide the care of the residents who are at risk for falls. The P/P indicated the residents who are medium to high risk for fall (with multiple risk factors and those who have fallen) will have interventions implemented to reduce the risk and severity of injuries due to falls as well as prevent falls from recurring, while supplementing fall prevention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056488 If continuation sheet Page 3 of 11 Printed: 05/15/2026 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 056488 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: 056488 If continuation sheet Page 4 of 11 Printed: 05/15/2026 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 056488 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on [DATE], was not administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) due to a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated [DATE] and [DATE] for accuracy, prior to transcribing the orders in Resident 10's chart. 2. RN 1 did not review and clarify conflicting instructions outlined in the GACH's Discharge Instructions dated [DATE] which indicated do not use Baclofen since caused confusion versus the Discharge instructions dated [DATE], which indicated Medications to Continue to Take with no Change which indicated Baclofen 10 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) give 0.5 tablet three times daily, with Resident 10's physician. 3. RN 1 administered 5 doses of Baclofen 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) to Resident 10 without reconciling the orders with Resident 10's physician. 4. RN 1 did not follow the facility's Policy and Procedure (P/P), titled, Medication Orders Non-Controlled Medication Order Documentation revised 8/20219, which indicated nurses are to verify the GACH's order with attending physician before medication (Baclofen) was transcribed for administration. These deficient practices resulted in Resident 10 receiving Baclofen 5 mg from [DATE] through [DATE] (a total of six doses), experiencing shortness of breath (SOB), elevated blood pressure (BP), generalized weakness and increased confusion. Resident 10 was transferred to a GACH, where he was diagnosed with acute toxic encephalopathy (a condition characterized by sudden and severe brain dysfunction caused by exposure to toxic substances) and was dialyzed (treatment to remove waste products and excess fluid from the blood when the kidneys are unable to do so). On [DATE] at 3:28 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), the Interim Chief Clinical Officer (CCO) and the Senior Nurse Executive (SNE) due to the facility's failure to recognize a discrepancy in the GACH's discharge instructions and follow up with Resident 10's attending physician to clarify discharge/transfer orders prior to transcribing Baclofen for administration to Resident 10. On [DATE], the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on [DATE] at 3:40 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: 1. On [DATE], Resident 10 was discharged to a GACH and was readmitted to the facility on [DATE] the admitting nurse verified the admissions orders with the attending physician. A medication error report for Baclofen was completed on [DATE] for the [DATE] admission orders and was reported to the attending physician and Resident 10's family. Resident 10 was discharged home on [DATE]. 2. On [DATE] the Interim Chief Clinical Officer (CCO)/ Designee provided a 1:1 (a personalized, process where an experienced person works directly with a learner to teach a specific task, process, or skill) in-service training to RN 1 on reviewing discharge orders, reconciling and verifying orders with attending physicians prior to carrying out the orders, the facility's P/P titled, Medication Orders Non-Controlled Medication Order Documentation which requires the licensed nurses to verify the GACH's order with attending physician before medications (Baclofen) are transcribed for administration. 3. On [DATE], a random audit of all in-house patients was completed by Health Information Manager (HIM) and the Interim Residents Affected - Few Note: The nursing home is disputing this citation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056488 If continuation sheet Page 5 of 11 Printed: 05/15/2026 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 056488 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. CCO/designee. A total of 12 residents who were receiving Baclofen were identified and there were no concerns. On [DATE], a random audit of all newly admitted residents in the past 24 hours was conducted by the HIM and Interim CCO/designee. A total of 10 residents identified and their physicians ‘orders were reviewed, reconciled with their attending physicians, no concerns were found. 4. On [DATE] the DSD/ Clinical Trainer provided re-training beginning to licensed nurses on entering orders into Electronic Treatment Administration Record ([eMAR/eTAR]) prior/pending confirmation, reconciliation and verification of orders. Licensed Nurses who are on leave, vacation, out sick or newly hired nurses will be educated prior to the start of their shift. 5. On [DATE], the DSD and the Clinical Trainer conducted an in-service training for licensed nursing staff on the facility's P/P titled, Medication Orders Non-Controlled Medication Order Documentation which requires the licensed nurses to verify the GACH's order with attending physician before medications is transcribed for administration. The training will continue until all licensed nursing staff have attended the training by [DATE]. Licensed Nurses who are on leave, vacation, out sick or newly hired nurses will be educated prior to the start of their shift. 5. On [DATE] during the ad hoc (created or done for a particular purpose when necessary or needed) QAPI (Quality Assurance/Quality Assurance and Performance Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee meeting, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the medication reconciliation error. RN 1, who was not the facility's regular admitting nurse, did not follow the reconciliation policy and bypassed physician verification, reflecting a knowledge gap in high-risk medication reconciliation requirements. Although the facility had a policy in place (Medication Orders Non-Controlled Documentation), it was not consistently applied, and there was no structured admission process to support nurses unfamiliar with admissions. Leadership oversight was also limited, with QAPI audits not consistently addressing reconciliation compliance and no real-time monitoring system to ensure medication reconciliation was completed upon admission. The RCA identified the root cause as the absence of a medication reconciliation process that ensured physician verification, standardized documentation, and active leadership oversight. 6. Team Members: Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, Regulatory Compliance Nurse. Each member will perform the following: i. Medical Director: will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medication errors. ii. Executive Director (ED): will oversee all corrective actions initiated on [DATE] and continue monthly reviews during QAPI meetings. iii. Chief Clinical Officer (CCO): will oversee the investigation, reporting, and resolution of medication reconciliation audit, ensuring patient safety and regulatory compliance. The CCO will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the DSD to provide ongoing training, reinforcing best practices in medication management. iv. Regulatory Compliance Nurse: This role entails staying updated on regulatory changes, collaborating with the interdisciplinary team to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. This role involves planning, developing, organizing, implementing, coordinating, and directing the quality assurance and assessment program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern the facility. v. Director of Staff Development: This role involves educating staff and plays a critical role in addressing medication reconciliation audits by providing targeted training and education to licensed nursing staff, ensuring compliance with facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056488 If continuation sheet Page 6 of 11 Printed: 05/15/2026 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 056488 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. policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.Findings: During a review of Resident 10's admission Record (Face Sheet), the Face Sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnosis including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage, end stage renal disease ([ESRD] irreversible kidney failure and was dependent on hemodialysis. During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 10 was able to make decisions that were reasonable and consistent. The MDS indicated Resident 10 required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 10's GACH's Discharge summary dated [DATE] and timed at 2:09 p.m., the Discharge Summary indicated to discharge Resident 10 to the facility with the following instructions. a. Do not use Baclofen since the medication caused confusion b. Administer Baclofen 10 mg, give 0.5 tablet, three times daily. During a review of the GACH's discharge instructions, dated [DATE] and timed 8:44 a.m., the Discharge Instructions indicated administer Baclofen 10 mg, give 0.5 tablet, three times daily During a review of Resident 10's Clinical Record there was no written documentation to indicate the admitting nurse (RN 1) notified Resident 10's physician to clarify conflicting instructions to determine if Baclofen should or should not be administered to Resident 10. During a review of Resident 10's Physician's Order Summary, the Physician Order Summary dated [DATE] indicated to administer Resident 10 Baclofen 10 mg, give 0.5 tablet three times a day for muscle spasms. During a review of Resident 10's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/2025, the MAR indicated Resident 10 was administered six doses of Baclofen 5 mg from [DATE] to [DATE]. During a review of Resident 10's Change of Condition Evaluation (COC) dated [DATE] and timed at 8:04 a.m., the COC indicated Resident 10 was observed with SOB, weakness, confusion and drowsiness, with a BP of 180/110 millimeters of mercury (mmhg-unit of measurement) and an oxygen saturation ([O2 Sat] oxygen level in the body that indicates the body has enough oxygen supply, normal range of 95 to 100%) rate of 92% to 94 % on room air. The COC indicated Resident 10's physician was notified of Resident 10's COC on [DATE] at 8:45 a.m., and an order was obtained to transfer Resident 10 to the GACH by paramedics. During a review of the Resident 10's Physician's Order Summary, dated [DATE], the Physician's Order Summary indicated to call 911 for Resident 10 because of SOB, elevated blood pressure and generalized weakness. During a review of the GACH's Emergency (ED) Note dated [DATE] and timed at 10:28 a.m., the ED Note indicated Resident 10 was brought to the emergency room by the paramedics because of dizziness, fatigue, and nausea with a BP of 182/69. During a review of the GACH's History and Physical dated [DATE] and timed at 5:08 p.m., the H&P indicated Resident 10 presented at the emergency room (ER) with new onset altered mental status ([AMS] a person not as awake, alert or able to understand or respond to their surroundings as they normally would be), dizziness, nausea and weakness after confirmed administration of Baclofen at the facility. The H&P indicated a few weeks ago, Resident 10 was hemodialyzed at another GACH (date unknown) related to Baclofen toxicity (the extent to which a substance is poisonous and harmful to living thing).The H&P indicated Resident 10 might have received a second unintentional dose of Baclofen and was placed on delirium precautions (simple actions used to help a confused person to stay calm and oriented), frequent reorientation, and admitted for acute encephalopathy, likely due to Baclofen toxicity. During a review of the GACH's Nephrology (a branch of medicine that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056488 If continuation sheet Page 7 of 11 Printed: 05/15/2026 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 056488 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. focuses on the diagnosis, treatment, and management of kidney diseases) Consultation Notes dated [DATE] and timed at 6:49 p.m., the Nephrology Consultation Notes indicated Resident 10 will undergo hemodialysis due to Baclofen toxicity. During a review of the GACH's Discharge summary dated [DATE] and timed at 2:44 p.m., the Discharge Summary indicated a diagnosis of acute toxin encephalopathy. During a review of Resident 10's Skilled Nursing Facility History and Physical (SNF H&P) dated [DATE] and timed at 12:45 p.m., the H&P indicated the facility's nursing department restarted Resident 10's home medications including Baclofen, The H&P indicated Resident 10's medications were started (transcribed and ordered) and administered to Resident 10, without clarifying the discharge medication list with the primary care physician (PCP). During a telephone interview on [DATE] at 12:23 p.m., Resident 10's Family Member (FM) 1 stated Resident 1 was transferred to the facility from a GACH on [DATE] with instructions not to give Resident 10 Baclofen because it made Resident 10 feel weak and confused. FM 1 stated on [DATE] Resident 10 called her complaining she did not feel well, and the facility had given her Baclofen. FM 1 stated she arrived at the facility at 10 a.m., and Resident 10 had been transferred to a GACH due to dizziness, fatigue, SOB and hallucinations. FM 1 stated when she arrived at the GACH, the GACH had not been informed by the facility that Resident 10 was given Baclofen or that it caused Resident 10 confusion. FM 1 stated she notified the GACH and the GACH immediately performed dialysis on Resident 10. FM 1 stated Resident 10 could have died because Resident 10's kidneys no longer functioned. During an interview on [DATE] at 4:11 p.m., RN 1 stated when she received Resident 10's admission papers from the GACH on [DATE], she determined Resident 10 was not allergic to any medication and transcribed the discharge medications listed on the GACH's Discharge Instructions. RN 1 stated she did not call Resident 10's physician to verify and/or clarify Resident 10's discharge medications or instructions because the physicians at the GACH normally prepare the discharge instructions and the primary care physician at the facility could see the orders in Resident 10's medical record. During a interview on [DATE] at 11:57 a.m., RN 1 stated after reviewing the Discharge summary dated [DATE], she did not see the instructions indicating Baclofen should not be given to Resident 10 due to confusion. RN 1 stated had she read the Discharge Summary, compared the GACH's discharge instructions, discharge medication list, and called Resident 10's physician to clarify the instructions, Resident 10 would never have been given Baclofen that caused a COC. During a telephone interview on [DATE] at 12:32 p.m., RN 3 stated on [DATE] during the 7 a.m. to 3 p.m. shift, she received endorsement from the outgoing nurse (11 p.m. - 7 a.m.) that Resident 10 was feeling weak and dizzy. RN 3 stated she assessed Resident 10 at the start of her shift (7 a.m. - 3 p.m.), and Resident 10 complained of right buttock pain, rated at 3 out of 10 on an eleven point scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) and she (RN 3) applied a lidocaine patch (a topical adhesive patch containing lidocaine, used for pain) to the affected site and gave Resident 10 5 mg of Baclofen. RN 3 stated at approximately 8:30 a.m., Resident 10 still felt weak, dizzy, had become more lethargic (a state of decreased consciousness such as fatigue, drowsiness or sleepiness) and was not talking, her B/P was high, she was SOB, and her O2 Sat was 92% on O2 (liters of O2 unknown). RN 3 stated she administered an anti-hypertensive medication to Resident 10, but her BP remained high, she (RN 3) then called Resident 10's physician and was given an order to call the paramedics. During an interview on [DATE] at 12:47 p.m., the SNE stated the admission process included checking the discharge papers from the GACH including the doctor's discharge summary, discharge instructions and the medication list. The SNE stated it was the responsibility of the admitting nurse to call Resident 10's physician to verify and/or reconcile the residents' medications to ensure the residents' prescribed medications were accurate. During a telephone interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056488 If continuation sheet Page 8 of 11 Printed: 05/15/2026 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 056488 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] 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] 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] 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] 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] 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] 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], 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: 056488 If continuation sheet Page 9 of 11 Printed: 05/15/2026 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 056488 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 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a QAPI (Quality Assurance/Quality Assurance and Performance Improvement - a data driven proactive approach to improvement used to ensure services are meeting quality standards) plan was implemented after being made aware of a deficient practice and failure of the facility, when one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on 8/15/2025, was administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) with a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated 8/14/2025 and 8/15/2025 for accuracy, prior to transcribing the orders in Resident 10's chart. 2. RN 1 did not review and clarify conflicting instructions outlined in the GACH's Discharge Instructions dated 8/14/2025 which indicated do not use Baclofen since caused confusion versus the Discharge instructions dated 8/15/2025, which indicated Medications to Continue to Take with no Change which indicated Baclofen 10 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) give 0.5 tablet three times daily, with Resident 10's physician. 3. Resident 10 was administered 5 doses of Baclofen without clarifying with her physician. 4. RN 1 did not follow the facility's Policy and Procedure (P/P), titled, Medication Orders Non-Controlled Medication Order Documentation revised 8/20219, which indicated nurses are to verify the GACH's order with attending physician before medication (Baclofen) was transcribed for administration. These deficient practices resulted in Resident 10 receiving Baclofen 5 mg from 8/15/2025 through 8/17/2025 (a total of six doses), experiencing shortness of breath (SOB), elevated blood pressure (BP), generalized weakness and increased confusion. Resident 10 was transferred to a GACH, where he was diagnosed with acute toxic encephalopathy (a condition characterized by sudden and severe brain dysfunction caused by exposure to toxic substances) and was dialyzed (treatment to remove waste products and excess fluid from the blood when the kidneys are unable to do so). See F684Findings: On 9/9/2025 at 3:28 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), the Interim Chief Clinical Officer (CCO) and the Senior Nurse Executive (SNE) due to the facility's failure to recognize a discrepancy in the GACH's discharge instructions and follow up with Resident 10's attending physician to clarify orders prior to transcribing Baclofen for administration to Resident 10. On 9/10/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 9/10/2025 at 3:40 p.m., in the presence of the facility's DON and ADM. Findings: During an interview on 9/9/2025 at 120 p.m., the Medical Director stated as far as he was not aware that a QAPI meeting had been conducted related to Resident 10's Baclofen administration but stated one should have been conducted so there was awareness and education started for the all licensed nurses. During an interview on 9/10/2025 at 11 a.m., the Chief Clinical Officer (CCO) stated she did not complete an incident report related to Resident 10's medication error and she did not meet with the QAPI members, and she should have met with them The CCO stated it was important for the facility to conduct a QAPI meeting immediately after they were made aware of the deficient practice in order to address any concerns, find the root cause, develop and implement interventions to ensure the same incident did not happen again. During an interview on 9/10/2025 at 12:33 p.m., the Administrator (ADM) stated he was informed of the grievance from the family, which the CCO met with Resident 10's family and investigated but there was no incident report filed Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056488 If continuation sheet Page 10 of 11 Printed: 05/15/2026 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 056488 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: 056488 If continuation sheet Page 11 of 11