Health inspection·December 5, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three residents (Resident 1) was free from rough handling and treated with dignity and respect, while being assisted by Certified Nurse Assistant (CNA) 1. This deficient practice resulted in a purplish discoloration to the left thumb, emotional distress, and loss of dignity and trust in staff. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple fractures (broken bones) of the ribs (right side), and motor vehicle accident (car accident). During a review of Resident 1's History and Physical (H& P) dated 9/19/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS]resident assessment tool) dated 9/14/2025, the MDS indicated Resident 1 had normal cognitive function and required dependent (helper does all the effort) with toileting and personal hygiene.During an interview on 12/4/2025 at 8:30 a.m. with Resident 1, Resident 1 stated on the morning of the incident on 11/19/2025 at approximately 10:00 a.m., CNA 1 appeared to be in a bad mood and had informed her that she would be receiving a shower that morning. Resident 1 stated she told CNA 1 that she prefers to be showered between 3:00 p.m. and 11:00 p.m., not in the morning. Resident 1 stated that CNA 1 responded, Why didn't you tell me that earlier? Resident 1 stated that this conversation occurred at approximately 10:30 a.m. Resident 1 stated that after the shower, CNA 1 left her in the wheelchair for approximately 30 minutes and told her that she was going to lunch. Resident 1 stated that after lunch she did not want to call for CNA 1 due to the CNA's earlier behavior. Resident 1 stated that she believed CNA 1 was upset because she had worked a double shift and appeared to be rushed. Resident 1 stated that CNA 1 came to her room between approximately 6:00 p.m. and 7:00 p.m. to bring her dinner. Resident 1 stated that she told CNA 1 at that time that she intended to report her concerns to a supervisor. Resident 1 stated while CNA 1 was trying to put her gown on she took her left hand and squeezed it very hard. Resident 1 stated she had informed CNA 1 to be careful with her left arm, explaining that she had previously been in an accident and fractured it. Resident 1 stated during the provision of care, she told CNA 1 that the CNA was handling her too roughly. Resident 1 stated that after she voiced her concern, CNA 1 did not respond and continued with care. Resident 1 stated that she later reported to the RN Supervisor, (RNS) that CNA 1 had not returned to her room and had left her bedside table a mess, without cleaning the area after care. Resident 1 stated she did not inform the RNS at that time about CNA 1 squeezing her left hand because she was afraid to report it. Resident 1 stated that on 11/20/2025, she noticed purplish discoloration on her left thumb. Resident 1 stated that she informed License Vocational Nurse (LVN) 1 and asked her to come into the room to look at the discoloration. Resident 1 stated at that time, she told LVN 1 that the injury probably happened when CNA 1 squeezed my hand while changing my gown the previous day. Resident 1 stated that during her care, she observed Page 1 of 3 056488 056488 12/05/2025 Sunnyside Nursing Center 22617 S. Vermont Ave Torrance, CA 90502

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA 1 appearing overwhelmed. Resident 1 stated that she believed this may have been because CNA 1 was working a double shift that day. Resident 1 stated that CNA 1 appeared to be rushing while providing the shower, which made her feel concerned about her care. Resident 1 stated that from the time she received her shower in the morning until the evening, when CNA 1 came in to bring her dinner tray, she did not call for assistance from CNA 1. Resident 1 stated that she chose not to call for help from the morning shower due to fear and concern regarding the CNA's earlier behavior. During an interview on 12/4/2025 at 8:45 a.m. with Resident 2, Resident 2 stated she heard Resident 1 telling CNA 1 that she was not handling her right. Resident 2 stated that the voices sounded loud, but she was unable to make out the full conversation between Resident 1 and CNA 1. During a telephone interview on 12/4/2025 at 9:33 a.m. with CNA 1, CNA 1 stated that on the day of the incident, she transferred Resident 1 into the shower chair, and after the transfer, Resident 1 informed her that she prefers to receive showers after 3:00 p.m. CNA 1 stated that the alleged incident occurred later in the evening when she was assisting Resident 1 with putting on her gown. CNA 1 stated that Resident 1 told her to be careful with her left arm prior to assistance, stating that she had a previous car accident which had fractured her left arm, and that lifting it too high could cause pain. CNA 1 stated that when she first attempted to lift the resident's arm, Resident 1 complained of pain, and CNA 1 immediately stopped. CNA 1 stated that she felt rushed during her interaction while showering the resident because she took a long time to shower and she needed to return to her other assigned residents. CNA 1 acknowledged that her feeling rushed may have contributed to handling Resident 1's left hand in a way that caused discomfort. CNA 1 stated that she did not intend to harm the residents, but she recognized that her actions could have potentially violated Resident 1's rights. During a telephone interview on 12/4/2025 at 11:14 a.m. with Unit Director of Nursing (UDON), the UDON stated that she was first made aware of the allegation on 11/20/2025 at 5:45 p.m. by LVN 1. who called her to Resident 1's room due to purplish discoloration on the resident's left thumb. The UDON stated she asked Resident 1 what had happened, and the resident stated the injury may have occurred the previous night while CNA 1 was assisting her with putting on her gown. The UDON stated Resident 1 stated that CNA 1 was rough with her when she raised her arm to put on her gown and squeezed her hand. The UDON stated she assessed Resident 1 upon being notified of the concern and during her assessment, she observed a purplish discoloration on the lower part of Resident 1's left thumb. The UDON stated that if a resident is roughly handled during care, the resident may feel afraid or unsafe. The UDON stated that the potential outcomes include refusal of care, fear of staff, and possible injury. During an interview on 12/4/2025 at 11:50 a.m. with Director of Nursing (DON), the DON stated that she was first made aware of the allegation on 11/20/2025 at 5:00 p.m. by the UDON, who informed her that Resident 1 reported being roughly handled by CNA 1. The DON stated, she instructed the UDON to send CNA 1 home, conduct a resident assessment, interview staff and other residents, and notify the administrator. The DON stated that when a resident is roughly handled during care, the resident may feel frightened, humiliated, or powerless, particularly when the resident is physically vulnerable. The DON stated that such an experience can cause a resident to feel unsafe with staff who provide hands-on care and may lead to the resident becoming withdrawn or reluctant to participate in care activities. The DON stated these outcomes place the resident at risk for decline in overall well-being and unmet care needs. During a telephone interview on 12/5/2025 at 8:43 a.m. with LVN 1, LVN 1 stated she was the charge nurse at the time Resident 1 reported the incident. LVN 1 stated Resident 1 informed her on 11/20/2025 at 5:20 p.m. inside Resident 1's room about the alleged incident. LVN 1 stated Resident 1 informed her on 11/19/2025, CNA 1 squeezed her left hand while trying to put her gown on. LVN 1 stated 056488 Page 2 of 3 056488 12/05/2025 Sunnyside Nursing Center 22617 S. Vermont Ave Torrance, CA 90502

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she assessed Resident 1 after the report and observed purplish discoloration on the resident's left lower thumb. LVN 1 stated the discoloration appeared fresh. LVN 1 stated Resident 1 reported the bruise came from the action of CNA 1. LVN 1 stated LVN 1 stated that she believes Resident 1's report regarding CNA 1's handling of her left arm was credible. LVN 1 stated she believed Resident 1's report is consistent with the observed injury, noting the purplish discoloration on the resident's left thumb. LVN 1 acknowledged that if a resident experiences discomfort or rough handling during care, this would constitute a violation of the resident's rights. LVN 1 stated that if a resident is roughly handled during care, it can cause the resident to feel afraid, anxious, and emotionally distressed. LVN 1 stated that that such an experience could result in the resident being fearful of asking for assistance, hesitant to accept care, and could negatively impact the resident's sense of safety and trust in staff. LVN 1 stated that residents have the right to feel safe and secure while receiving care. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2024, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity. 056488 Page 3 of 3