Health inspection·November 13, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders and care plan for two of three sampled residents (Resident 1 and Resident 2) by failing to:1. Follow Physician's Order to limit the resident's sitting to one to two hours at a time with gel cushion on the wheelchair for Resident 1.2. Follow Physician's Order to adjust Alternating Pressure Mattress Replacement System with Low Air Loss (APMRS, mattress that provided pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body were reduced) settings according to Resident 1's height and weight.3. Implement Resident 1's care plan to limit the resident's sitting to one to two hours at a time with gel cushion on the wheelchair and adjust the APMRS settings according to the resident's height and weight.4. Follow Physician's Order to adjust APMRS settings according to Resident 2's weight.5. Implement Resident 2's care plan to adjust APM settings according to the resident's weight.This deficient practice had the increased potential for Resident 1 and Resident 2 to develop new pressure ulcer (localized damage to the skin and/or underlying soft tissue, most often caused by prolonged pressure, but also by friction and shear) or injury and/or delay the resident's wound to heal. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and anemia (a condition where the body did not have enough healthy red blood cells). During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (a simple tool used to predict a person's risk of developing a pressure sore [bedsore, a type of skin and tissue damage caused by constant pressure, friction, or shearing that cut off blood flow to an area, often on bony parts of the body] by rating six key factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear) dated 3/11/2024 at 6:20 PM, the Braden Scale indicated the resident's sensory perception was slightly limited, the resident's skin exposure to moisture was occasional, bedfast, slightly limited mobility, inadequate nutrition, and had a potential friction and shear problem. The Braden Scale indicated a score of 14, categorizing Resident 1 at moderate risk for pressure sore risk. During a review of Resident 1's Physician's Order dated 11/9/2024 at 11:50 AM, the Physician's Order indicated for the resident to have a low air loss mattress (an air-filled bed that prevented skin sores by using a gentle, continuous flow of air to keep the resident dry and cool, often combined with an alternating pressure feature that cycles air to redistribute pressure points) for skin management, setting according to resident weight and height and check function every shift. During a review of Resident 1's History and Physical (H&P) dated 3/11/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 1's Physician's Order dated 4/9/2025, the Physician's Order indicated for the resident to limit sitting to one to two hours at a time with gel cushion (a seat or pad made of a gel Residents Affected - Some Page 1 of 7 055430 055430 11/13/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some material, often combined with foam, that provided pressure relief and support by conforming to the body's shape) on the wheelchair every day and evening shift. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/9/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated that the resident was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. The MDS indicated treatments for Resident 1's skin and ulcer/injury included pressure reducing device for chair, pressure reducing device for bed, and pressure ulcer/injury care. The treatment did not include a turning/repositioning program. During a review of Resident 1's Risk for Pressure Ulcer Development Care Plan revised 9/17/2025, the Care Plan indicated a goal for the resident to have no pressure ulcer development, show signs of healing, and remain free from infection. The Care Plan indicated interventions to limit sitting to one to two hours at a time with gel cushion on the wheelchair as per physician every day and evening shift; low air loss mattress for skin management setting according to resident height and weight and check function daily; and monitoring/reminding/assistance to turn/reposition. During a review of Resident 1's Turning Schedule Every 2 Hours dated 10/26/2025, the Turning Schedule had times listed in two-hour increments starting at 7:30 AM to 5:30 AM. The Turning Schedule did not have a staff signature from 7:30 AM to 1:30 PM and from 11:30 PM to 5:30 AM. During a review of Resident 1's Turning Schedule Every 2 Hours dated 10/29/2025, the Turning Schedule did not have a staff signature from 11:30 PM to 5:30 AM. During a review of Resident 1's Turning Schedule Every 2 Hours dated 10/30/2025, the Turning Schedule did not have a staff signature from 11:30 PM to 5:30 AM. During a review of Resident 1's Turning Schedule Every 2 Hours dated 11/3/2025, the Turning Schedule did not have a staff signature from 11:30 PM to 5:30 AM. During a review of Resident 1's Weight Summary dated 11/10/2025, the Weight Summary indicated the resident's weight was 121 pounds. During an observation in Resident 1's Room on 11/13/2025 at 10:10 AM, the resident's low air loss mattress analog pressure dial (device with a needle that pointed to a number on a round, numbered dial to show the pressure reading) was pointed between 250 pounds and 300 pounds. During an observation of Resident 1 on 11/13/2025 from 10:10 AM to 1:12 PM, Resident 1 was seated on a wheelchair, first in the activity room and then positioned in the hallway. Resident 1 was seated in a wheelchair for roughly three hours. During a concurrent interview and record review of Resident 1's Turning Schedule Every 2 Hours on 11/13/2025 at 12:26 PM, the Certified Nursing Assistant (CNA) 1 stated she would sign the document at the end of the day but should have been signing the document every two hours after turning and repositioning Resident 1. CNA 1 stated if there was no documentation, the facility would not know if the turning and repositioning of the resident was done and the facility staff could just say they turned the resident without actually turning the resident. CNA 1 stated for Resident 1, she must be turned every two hours because the resident could easily get bed sores. During a concurrent observation and interview on 11/13/2025 at 1:20 PM, the Treatment Nurse (TN) stated the setting for Resident 1's low air loss mattress depended on the resident's weight and should have been between 120 to 150 pounds because the resident weighs 121 pounds. The TN stated the setting for Resident 1 was not correct and because the mattress was hard if the resident turned, the resident could flip over and Resident 1 could fall off the bed. During a concurrent interview and record review of Resident 1's Physician's Order on 11/13/2025 at 1:31 PM, the TN stated the facility was not following the orders to set the resident's low air loss mattress according to Resident 1's weight and height but should have been. The TN stated the facility staff should have checked the low air loss mattress all the time or the resident could fall off the bed and have a fracture (break in a bone) or bruise (a mark on 055430 Page 2 of 7 055430 11/13/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the skin caused by a bump or impact that damaged small blood vessels under the surface without breaking the skin). During a concurrent interview and record review of Resident 1's Turning Schedule Every 2 Hours on 11/13/2025 at 1:49 PM, the Licensed Vocational Nurse (LVN) 1 stated the resident should have been turned every two hours but there was no documentation that Resident 1 was turned but there should have been. LVN 1 stated if there was no documentation then the facility would not be able to have confirmed if the resident was repositioned and there was a possibility for redness on the resident's skin or pain/discomfort. During a concurrent interview and record review of Resident 1's Physician's Order on 11/13/2025 at 2:10 PM, CNA 1 stated the facility was not following the orders for the resident to be sitting one to two hours at a time with a gel cushion on the wheelchair but should have been, otherwise Resident 1 could have skin breakdown. During an interview on 11/13/2025 at 2:38 PM, the TN stated the facility staff were not following the orders for Resident 1 to be sitting one to two hours at a time with a gel cushion on the wheelchair. The TN stated the facility staff should have been following the orders to prevent Resident 1's pressure sore from opening again. During a concurrent interview and record review of Resident 1's Turning Schedule Every 2 Hours on 11/13/2025 at 4:30 PM, the Director of Nursing (DON) stated the form should have been filled out completely to ensure the nurse checked the resident and turning/repositioning was done every day. During a concurrent interview and record review of Resident 1's Physician's Order on 11/13/2025 at 4:38 PM, the DON stated the facility staff were not following the orders because Resident 1 was sitting in the wheelchair for longer than two hours. The DON stated if the resident was sitting on the wheelchair for more than two hours the resident's closed wound could become open because the skin was already fragile and could affect the resident's daily living. During a concurrent interview and record review of Resident 1's Risk for Pressure Ulcer Development Care Plan on 11/13/2025 at 4:41 PM, the DON stated the facility was not following the care plan but should have been. The DON stated if the facility was not following the care plan the resident's wound could reopen. During a concurrent observation and interview of Resident 1's low air loss mattress on 11/13/2025 at 4:44 PM, the DON stated the setting was not correct for the resident's weight but should have been. The DON stated if the setting was not correct Resident 2's wound could possibly reopen. 2. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included pressure ulcer of sacral region stage four (the protective layers of skin have been completely destroyed, and the underlying tissue like muscle or bone was exposed and damaged), atrophy (the wasting away or decrease in size of a body part, cell, or tissue), and anemia. During a review of Resident 2's H&P dated 5/27/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Braden Scale for Predicting Pressure Sore Risk dated 6/20/2025 at 11:08 PM, the Braden Scale indicated the resident did not have sensory impairment, the resident's skin exposure to moisture was occasional, chairfast, very limited mobility, adequate diet, and had a problem with friction and shear. The Braden Scale indicated a score of 14, categorizing Resident 2 at a low risk for pressure sore risk. During a review of Resident 2's Physician's Order dated 8/12/2025 at 3:03 PM, the Physician's Order indicated for the resident to have a low air loss mattress for skin management, setting according to resident weight and check function every shift. During a review of Resident 2's Risk for Pressure Ulcer Development Care Plan revised 8/15/2025, the Care Plan indicated a goal for the resident's pressure ulcer to show signs of healing and remain free from infection. The Care Plan indicated interventions to provide low air loss mattress for wound management, administer treatments as ordered and monitor for effectiveness, and required pressure relieving/reducing device on bed/chair. During a review of Resident 2's MDS dated [DATE], the MDS indicated the 055430 Page 3 of 7 055430 11/13/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated that the resident was at risk of developing pressure ulcers/injuries. The MDS indicated treatments for Resident 1's skin and ulcer/injury included pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention, application of nonsurgical dressings, and applications of ointments/medications. The treatment did not include a turning/repositioning program. During a review of Resident 2's Weight Summary dated 10/6/2025, the Weight Summary indicated the resident's weight was 215 pounds. During an observation in Resident 2's Room on 11/13/2025 at 12:12 PM, the resident's low air loss mattress analog pressure dial was pointed between 250 pounds and 300 pounds. During a concurrent observation and interview on 11/13/2025 at 1:36 PM, the TN stated the setting for Resident 2's low air loss mattress should have been between 200 and 215 pounds. The TN stated the setting for Resident 2 was not correct and if the resident was reaching for something the low air loss mattress could flip the resident because the mattress moves with the resident. During a concurrent interview and record review of Resident 2's Physician's Order on 11/13/2025 at 1:40 PM, the TN stated the facility was not following the orders to set the resident's low air loss mattress according to Resident 2's weight but should have been. The TN stated the facility staff should have checked the low air loss mattress all the time or the resident could fall off the bed and have a fracture or bruise. During a concurrent observation and interview of Resident 2's low air loss mattress on 11/13/2025 at 4:55 PM, the DON stated the setting was not correct for the resident's weight but should have been. The DON stated if the setting was not correct Resident 2's wound could possibly reopen. During a review of the undated User Manual for Resident 1's Alternating Pressure Mattress Replacement System with Low Air Loss, the User Manual indicated the system was a High quality powered air support surface that was specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort. The User Manual indicated Effective pressure redistribution therapy, wound management and device selection should be based on the patient's specific clinical condition and complete assessment of needs.Support surfaces are not substitutes for turning, repositioning or functional weight shifts. The User Manual indicated the Analog Pressure Dial Adjust the dial to correspond to the patients' appropriate weight setting or comfort level. During a concurrent interview and record review with the DON of the facility's policy and procedure (P&P) titled Skin and Wound Monitoring and Management dated December 2023, the P&P indicated Braden Scale for pressure injury risk should be completed on admission, weekly for the first four (4) weeks after admission, then quarterly and whenever there is a change in the resident's condition. The P&P indicate for prevention Reposition the resident. The DON stated the facility was not following the policy but should have been because the risk factors would be for the residents' wound to reopen or worsen. During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated December 2023, the P&P indicated It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 055430 Page 4 of 7 055430 11/13/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and secured environment for one of two sampled residents (Resident 1) who has a diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities) by mistakenly sending Resident 1 without supervision to a Physicians (Orthopedic- a medical specialty that focuses on the musculoskeletal system, which includes bones, joints, ligaments, tendons, and muscles) appointment outside the facility that was scheduled for another resident (Resident 2) on 11/12/2025. This deficient practice resulted in Resident 1 leaving the facility, unsupervised, to the Orthopedic physician's office, which was eleven (11) miles away from the facility, and had the potential for Resident 1 to be at risk for accidents and/or injuries.FINDINGS:During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE]. The AR indicated the resident's diagnoses including Cerebral infarction (when the blood supply to part of the brain is blocked or reduced.), Dementia (loss of memory, language, problem-solving and other thinking abilities). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/18/2025, indicated that Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 requires maximal assistance (helper does more than the half the effort) in toileting, shower, lower body dressing and putting on and taking off footwear. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) in oral hygiene, upper body dressing and personal hygiene, chair to bed transfers. The MDS indicated Resident 1 had an active diagnosis of Dementia. A review of Resident 1's Progress Notes dated 11/06/2025, written by Social Service Director (SSD), indicated Orthopedic appointment with Physician 1 on 11/12/2025 at 10 AM. The Note indicated, Called transportation and confirmed. Pick up time in the facility at 9:05 AM. RP 1 made aware and will meet Resident 1 at the clinic. A review of Resident 1's Progress Notes dated 11/12/2025, timed at 9:48 AM and written by Social Service Director (SSD), indicated at 9:30 AM, SSD received a telephone call from Responsible Party (RP) 1 who stated RP 1 was informed via a text message informing RP 1 that Resident 1 was picked up by transportation, and that RP 1 was unaware that Resident 1 was leaving the facility. The Note indicated that SSD called the medical office to where Resident 1 was going to, and to watch over Resident 1 when she arrived at the medical office. The Note indicated SSD called the transportation to check on the status on Resident 1, and transportation stated Resident 1 was dropped off five (5 minutes) ago. The Note indicated SSD informed transportation to turn back around and pick up Resident 1 at the dropped off location (medical office). The Note indicated SSD called the medical office to confirm that Resident 1 arrived at the medical office. The Note indicated transportation arrived back to pick up Resident 1 at the medical office at approximately 9:55 AM, and returned to the facility at 10: 20 AM. A review of Resident 2's AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of fracture to the right femur and orthopedic aftercare. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS of 15 (no cognitive impairment). The MDS indicated Resident 2 was independent with eating and oral hygiene. The MDS indicated Resident 2 required supervision with upper body dressing. The MDS indicated Resident 2 required maximum assistance with toileting. The MDS indicated Resident 2 was dependent with showers, lower body dressing, and putting on/taking off footwear. During a telephone interview on 11/12/2025 at 12:13 PM with RP 1, RP 1 stated this morning she received a text alert from a transportation company indicating Resident 1 was on-route. RP 1 stated she was able to see on the message the route began at the facility where Resident 1 resides to an unknown ending address for RP 1, which was a medical office. RP 1 stated she was 055430 Page 5 of 7 055430 11/13/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confused and alarmed as she had not received any notification from the facility that Resident 1 was leaving the facility. RP 1 stated Resident 1 has Dementia and was very forgetful and should not go anywhere unaccompanied as she could get lost or hurt. RP 1 stated she immediately called the facility to ask where Resident 1 was going. RP 1 stated she spoke to Case Manager Assistant (CMA) who stated she was unaware that Resident 1 was not in the facility, and CMA transferred the call to SSD. RP 1 stated the facility staff was unaware Resident 1 was mistakenly sent to Resident 2's appointment, and that RP 1 stated there was no urgency from facility staff to locate Resident 1. RP 1 stated she hung up with facility and drove to the unknown medical office address to locate Resident 1 herself as she was afraid Resident 1 would be scared, anxious and confused, since Resident 1 was being taken to an unknown location by herself. RP 1 stated the facility was only alerted to their mistake when RP 1 called the facility to check on Resident 1's wellbeing. During an interview on 11/12/2025 at 1:52 PM with Director of Nursing (DON), DON stated Resident 1 had been sent out to a medical appointment unaccompanied by mistake. DON stated the facility had three (3)residents with the same first name and somehow SSD entered an order for a Medical appointment and booked transportation for Resident 1, when the appointment and transportation was intended for Resident 2. During an interview on 11/12/2025 at 1:08 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was not familiar with Resident 1 and was unaware she had a diagnosis of Dementia. LVN 1 stated at the beginning of his shift he saw an appointment folder that had been prepared by the previous shift for Resident 1. LVN 1 stated he checked the facility appointment calendar and saw Resident 1 had a scheduled doctor's appointment at 10 AM, he then proceeded to notify CNA 1 to get Resident 1 ready for her appointment. LVN 1 stated he saw Resident 1 already seated in her wheel chair around 8:50 AM - 9:00 AM, and gave Resident 1 the envelope to give to the doctor. LVN 1 stated he did not see when Resident 1 left. LVN 1 stated while he was doing medication pass around 9:50 AM he noticed Resident 1 sitting in her wheelchair in front of the nurses station he then proceeded to ask social service assistant (SSA) who he saw walking by if Resident 1 had gone to her appointment to which SSA notified him the appointment was scheduled by mistake. LVN 1 stated he did not know that Resident 1 had a diagnosis of Dementia, and if he knew, verification to Resident 1's RP would have been made to confirm Resident 1 could leave the facility to a scheduled appointment, unaccompanied, per RP 1's wishes. During an interview on 11/12/2025 at 3:13 PM with Resident 1, Resident 1 stated a taxi man (a professional who drives a public passenger vehicle) came and took her somewhere this morning and could not remember whereas my mind is not all here. Resident 1 stated she asked the driver where he was taking her. Resident 1 stated all she remembered was the driver saying, don't worry it's not going to bother you. Resident 1 stated when the taxi man stated that, Resident 1 felt anxious and afraid because she had never gone anywhere without her sisters or daughter. During an interview on 11/12/2025 at 3:20 PM with Social Service Director (SSD), SSD stated she received a call from CMA stating Resident 1's RP 1 was on the telephone asking if Resident 1 had gone out to an appointment. SSD stated RP 1 informed SSD that RP 1 received a notification from a transportation company notifying RP 1 that Resident 1 was on her way to a clinic. SSD stated she would investigate and call RP 1 back. SSD stated realizing that Resident 1 was mistakenly sent to an appointment, which was intended for Resident 2. SSD stated she called the transportation company to tell transportation to return Resident 1 back to the facility. SSD stated she then received a call from the physician's office stating there was a resident (Resident 1) in their office who had been dropped off by transportation but did not know why she was there and that Resident 1 did not have an appointment. SSD stated she asked the physician's office receptionist to please keep the resident and watch her as Resident 1 was sent by mistake and has Dementia. SSD stated 055430 Page 6 of 7 055430 11/13/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she did not know how Resident 2's physician appointment was inputted by mistake into Resident 1's medical record, in which SSD inputted the appointment herself. SSD stated there must have been a glitch (malfunction or irregularity) in the system, since SSD could not explain how Resident 1 was scheduled for an appointment instead of Resident 2. During an interview on 11/13/2025 at 1:44 PM with Registered Nurse (RN 1), RN 1 stated Resident 1 should not go to appointments by herself unless it was requested by RP 1. RN 1 stated if RP requested for Resident 1 to travel alone, the nurse assigned to Resident 1 should have called RP 1 to verify their request and, should have called RP 1 before Resident 1 left the facility to confirm they were at the agreed upon location and let them know Resident 1 would be leaving the facility. RN 1 stated Resident 1's nurse should have notified the transportation driver about Resident 1's diagnosis to ensure Resident1 would not be left alone or unattended. During an interview on 11/13/2025 at 3:53 PM with Director of Nursing (DON), DON stated the nurse for Resident 1 should have called Resident 1's RP before Resident 1 left the facility to let RP 1 know Resident 1 was about to leave the facility, and to confirm that RP 1 would be waiting for Resident 1 at the doctor's office. During a review of the facility's Policy and Procedure (P&P) Out on Pass or Leave of Absence, with a revision date of 1/2022, the P&P indicated the following information It is the policy of this facility that continuity of care during resident leave of absence or while out on a pass will be maintained. Furthermore, the facility further stated Purpose: to provide a mechanism for continuity of care while a resident is away from the Facility for short periods. 055430 Page 7 of 7