Health inspection·May 30, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of one sampled resident (Resident 4), when Resident 4 ' s indwelling Foley catheter (a thin, flexible tube inserted into the bladder to drain urine continuously) urinary drainage bag (urine drainage bag to collect urine) was observed without a urinary drainage bag cover. This deficient practice had the potential to violate resident rights to maintain and enhance self-esteem, self-worth, and the right to be treated with dignity and respect. Findings: A review of Resident 4 ' s, admission Record (AR), dated 5/30/2025, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning — thinking, remembering, and reasoning), benign prostatic hyperplasia (BPH) (enlarged prostate, is a non-cancerous condition where the prostate gland grows larger than normal, leading to urinary problems), and acute kidney failure (kidneys suddenly stop working properly). A review of Resident 4 ' s History and Physical Examination (H&P), dated 5/1/2025, indicated Resident 4 does not have the capacity to understand and make decisions. A review of Resident 4 ' s Minimum Data Set (MDS-a resident assessment tool) dated 5/7/2025, the MDS indicated Resident 4 ' s cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 4 required setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene and dressing, and substantial/maximal assistance (helper does more than half the effort) with bathing and toileting. A review of Resident 4 ' s facility Order Summary Report, dated 5/30/2025, indicated Resident 4 had a Foley catheter attached to a drainage bag for urinary retention secondary to BPH. During an observation on 5/30/2025 at 1:15 PM in Resident 4 ' s room, Resident 4 was in bed with the head of bed elevated. Resident 4 ' Foley catheter urinary drainage bag was uncovered, exposing yellow urine inside the bag. During an interview on 5/30/2025 at 1:17 PM in Resident 4 ' s room, with license vocational nurse (LVN )1 stated Resident 4 ' s urinary drainage bag did not have a cover, and it should be covered to protect Resident 4 ' s dignity, and that covering urinary drainage bags was the policy of the Page 1 of 4 055764 055764 05/30/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0550 facility. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/30/2025 at 3:00 PM with the Director of Staff Development (DSD), DSD stated, Foley catheter urinary draiage bag should always be covered to protect residents ' dignity and residents ' rights. Residents Affected - Few During an interview on 5/30/2025 at 3:40 PM with the Director of Nurses (DON), DON stated, urine catheter drainage bag should have a cover, Resident 4 ' s urine bag not being covered violates residents ' dignity and resident rights. A review of the facility ' s policy and procedure (P&P) titled, Quality of Life – Dignity, dated 2/2020, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, self-worth and self-esteem. The P&P indicated residents were always treated with dignity and respect, and that demeaning practices and standards of care that compromise dignity are prohibited, example staff are expected to help resident to keep urinary catheter bag covered. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 2/2021, indicated employees shall treat all residents with kindness, respect and dignity. The P&P indicated federal and state laws guarantee certain basic rights to all residents which includes, dignified existence, be treated with respect and dignity, and privacy and confidentiality. 055764 Page 2 of 4 055764 05/30/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure nurse staffing information that was indicated on the Daily Skilled Nursing Facility (SNF) Staffing for certified nurse assistants (CNA) was accurate. Residents Affected - Few This deficient practice had the potential to misinform residents and visitors of the number of CNA's providing care to the residents. Findings: A review of the facility provided document for Daily Skilled Nursing Facility (SNF) Staffing Posting, dated 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 for the 11 PM to 7 AM shift, the document indicated the staff posting for actual hours worked for CNAs for the 11 PM to 7 AM shifts was 32 hours, and that the staffing total for CNAs was four (4). A review of the facility documents titled Nursing Staffing Assignment and Sign-In Sheet, dated 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 for the 11 PM to 7 AM shift, the document indicated, three (3) CNAs worked on 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 for the 11 PM to 7 AM shift, which should total 24 hours. During a concurrent interview and record review on 5/30/2025 at 3 PM with the Director of Staff Development (DSD), the facility documents titled Daily SNF Staffing Posting, dated 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 and the facility documents titled Nursing Staffing Assignment and Sign-In Sheet, dated 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 were reviewed. DSD stated, on 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 11PM to 7 AM there was only three CNAs who worked those shifts. DSD stated, she was responsible for completing the staff posting. The DSD stated the Staffing Posting was inaccurate since the correct number of CNAs who worked on 5/23/2025, 5/24/2025, 5/28/2025 and 5/29/2025 was 3 and not 4, and that the Staffing Posting should indicate CNA hours as 24, not 32 hours. DSD stated, not having the accurate information would mislead the visitors and residents at the facility. During an interview on 5/30/2025 at 3:00 PM with the Director of Nurses (DON), the DON stated, the staff posting on 5/23/2025, 5/24/2025, 5/28/2025, and 5/29/2025 indicated the actual hours of the 11 PM to 7 AM CNAs was 32 and was inaccurate since the staff posting should have indicated 24 hours for the CNA's hours since there were only three (3) CNA's working that shift. DON stated, staff posting was important for visitors and the residents to show the facility had an adequate number of staff to care for the residents in the facility. we. DON stated, when the staff posting was inaccurate, misinformation to the visitors and residents could occur. DON stated, the staff posting must be revised to indicate accurate information. A review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised 8/2022, indicated the facility would post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to resident. The P&P indicated within two hours of the beginning of each shift the number of licensed nurses (RNs, LPNs, and LVNs) directly responsible for resident care was posted in a prominent location (accessible to residents and visitors) and in clear and readable format, and that the information recorded on the form shall include, type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility, and actual time worked during 055764 Page 3 of 4 055764 05/30/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0732 that shift for each category and type of nursing staff. The P&P indicated the staffing information would be made available to residents, family members, and the public within 24 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055764 Page 4 of 4