Health inspection·December 16, 2025

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 develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for two of three sampled residents (Resident 1 and Resident 2) incident on 12/3/2025 by failing to:1. Implement a care plan for Resident 1 after multiple facility staff stated the resident was scared of Resident 2.2. Implement a care plan for Resident 2 after the resident experienced right arm numbness and vision loss.These deficient practices had the potential for a lack of individualized care and to not address Resident 1's well-being and Resident 2's care needs effectively.Findings: a. 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 hemiplegia and hemiparesis following cerebral infarction, affecting left non-dominant side (paralysis [the loss of the ability to move some or all parts of the body, resulting from damage to the nervous system], weakness [the state or condition of lacking strength] on the left side after a stroke [when blood flow to part of the brain was blocked or a blood vessel burst cutting off oxygen and nutrients, causing brain cells to die and leading to lasting damage or death] meant the right side of the brain [non-dominant for most] was damaged, controlling the left body), difficulty in walking, and history of falling. During a review of Resident 1's History & Physical (H&P) dated 8/14/2025, the H&P indicated the resident could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/18/2025 indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated Resident 1 rarely felt lonely or isolated and did not exhibit physical or verbal behavioral symptoms toward others. The MDS indicated resident 1 was dependent on facility staff (helper did all of the effort or the assistance of two or more helpers were required) from rolling to the left and to the right, sit to lying, lying to sitting on the side of the bed, sit to stand, and for transfers. During a review of Resident 1's Comprehensive (Complete) Care Plan dated 12/3/2025, the Care Plan did not include the incident, interaction, or Resident 1's response between Resident 1 and Resident 2's incident on 12/3/2025. During a review of Resident 1's Nursing Progress Note dated 12/3/2025 at 10:13 PM, the Progress Note indicated the resident was awake, alert and crying hysterically while verbalizing I don't want to go back to that room, she's crazy and I don't want to go back to that room. I'm scared that lady might kill me. The Progress Note indicated Resident 2 was noted by the facility Certified Nursing Assistant (CNA) standing and staring at Resident 1 by the head part of Resident 1's bed. The Progress Note indicated Resident 1 verbalized she (Resident 1) was in so much pain to her left posterior neck down to her left hip and when the facility staff educated the resident to go back to bed Resident 1 verbalized understanding and insisted on staying on her wheelchair because Resident 1 did not want to go back to her (Resident 1) bed. The Progress Note indicated the resident was Page 1 of 3 055430 055430 12/16/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hysterical crying intermittently and when the Physician's Assistant assessed Resident 1, the resident verbalized not feeling safe with roommate. During a review of Resident 1's Change in Condition Evaluation dated 12/3/2025 at 10:14 PM, the Evaluation indicated the resident had a fall in the evening and Resident 1 was screaming that the other patient is scaring her. The Evaluation indicated the resident complained of pain to the left upper back going down to the lower back with a pain level of nine from a zero to 10 pain scale (zero was no pain, four to five was moderate pain, and 10 was excruciating pain) and the resident received Tylenol. The Evaluation indicated the resident's Emergency Contact (EC) and the physician was notified with orders to transfer Resident 1 to the hospital. During a review of Resident 1's Nursing Progress Note dated 12/3/2025 at 10:23 PM, the Progress Note indicated when Licensed Vocational Nurse (LVN) 1 entered the room, Resident 2 was standing in between Bed A and Bed B and noted the intravenous pole (IV pole, a tall, often wheeled stand with hooks used to hold bags of fluids or medications) was on the floor and the cables for the call light was unplugged. The Progress Note indicated during that time, Resident 1 was hysterically screaming and said Resident 2 was trying to sit on her so she got scared and tried to get away. The Progress Note indicated Resident 1's EC was going to call the Police Department (PD) but the facility staff convinced her to talk to the facility supervisor first. The Progress Note indicated upon assessment of Resident 1, the resident was complaining of pain on her left upper back going down to her lower back and received pain medication. The Progress Note indicated the resident did not want to go back to her room because she was scared. During a review of Resident 1's Nursing Progress Note dated 12/3/2025 at 11:34 PM, the Progress Note indicated the resident stated she was asleep and felt something by the head part of the bed and when Resident 1 opened her eyes, she saw Resident 2 looking at me. The Progress Note indicated Resident 1 informed Resident 2 to stay away from me but Resident 2 did not listen. The Progress Note indicated that was when Resident 1 stood up from the bed to get her cell phone to call the EC and fell on the floor screaming for help. During a review of Resident 1's Interdisciplinary Team (IDT) Progress Note dated 12/5/2025 at 10:30 AM, the Progress Note indicated the same information as the 12/3/2025 at 11:34 PM progress note in regard to Resident 1's response to the incident. The Progress Note indicated Resident 2 had a severe headache and suddenly became blind, did not see anything and stood up trying to walk and see around. The Progress Note indicated a recommendation to follow up with Resident 1 when she returned to the facility for further intervention. b. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a general term for brain dysfunction caused by a sudden or gradual chemical imbalance from an underlying illness) and major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life). During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR, a structured communication tool used in healthcare to provide concise, critical information clearly, especially for urgent matters) dated 12/3/2025, the SBAR indicated the resident had right arm numbness and vision loss. The SBAR indicated the residents EC and physician were notified with orders to monitor and transfer out to the hospital for new episodes. During a review of Resident 2's Comprehensive Care Plan dated 12/3/2025, the Care Plan did not include the incident, interaction, or Resident 2's actions between Resident 1 and Resident 2's incident on 12/3/2025. During a review of Resident 1's Social Services Progress Note dated 12/4/2025 at 11:14 AM, the Progress Note indicated the Social Worker followed up with Resident 2 regarding the incident on 12/3/2025. The Progress Note indicated Resident 2 explained she sat up on her bed and was having a really bad migraine and all of a sudden her vision went black and 055430 Page 2 of 3 055430 12/16/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accidentally knocked down a pole and Resident 1 got scared and accidentally fell. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impact their daily life). The MDS indicated the resident did not have hallucinations. The MDS indicated the resident's active diagnoses included depression, and encephalopathy. During a review of Resident 2's H&P dated 12/6/2025, the H&P indicated the resident did not have the capacity to make medical or financial decisions. During a concurrent interview and record review of Resident 2's Care Plan on 12/16/2025 at 4:03 PM, the DON stated a care plan was the plan of care for that resident so the facility staff would know what care to provide and the resident's preferences if they had any. The DON stated the care plan would include pretty much everything like nutrition, medications, diagnosis, or if the resident was at risk for anything. The DON stated the facility staff should have been more specific on the behavior of what happened during the incident on 12/3/2025 in case Resident 2 did that again. During a review of the facility's policy and procedure (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. The P&P indicated, The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. 055430 Page 3 of 3