Health inspection·August 8, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure one of two sampled residents (Resident 1) who was assessed with contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) received treatment and care services in accordance with the resident's care plan for by failing to: 1. Ensure facility staff implemented Resident 1's care plan developed on 7/21/25 to immobilize the resident's right arm, to hold Range of Motion (ROM - a type of exercise designed to maintain and improve the flexibility and movement of joints) exercises as evidence by documentation survey report indicating exercises to the right arm was performed on 7/21/25, 7/22/25.2. Ensure facility staff follow physician's orders to hold range of motion exercises and [elbow extension] splinting to the right arm as evidence by documentation survey report indicating ROM by CNA daily care was conducted on 7/21/25, 7/22/25, 7/23/25. This deficient practice had potential to result in further decline, pain, and injury to the right upper arm. Findings: During a review of Resident 1's admission Record (AR), The AR indicated Resident 1was self responsible and admitted to the facility on [DATE] with a diagnosis hemiplegia (severe or complete loss of strength), and hemiparesis (partial weakness), aphasia language disorder that affects a person's ability to communicate), chronic respiratory failure (a long-term condition where the lungs can't adequately exchange oxygen and carbon dioxide, leading to insufficient oxygen in the blood or excessive carbon dioxide buildup, or both), Parkinson's Disease (a progressive neurodegenerative disorder that primarily affects movement, but also includes non-motor symptoms), gastrostomy (a surgically created opening (stoma) in the abdomen that allows for the placement of a tube into the stomach, typically for feeding or medication administration when a person cannot eat or drink adequately), tracheostomy (a surgical procedure that creates an opening in the neck to access the trachea [windpipe], allowing for breathing and/or the removal of secretions), dependence on ventilator and contractures of the right and left elbow, right and left hand, right and left hip, and right and left knee. During a review of Resident 1's History & Physical (H&P) dated 5/25/25, the H&P indicated Resident 1 did not have the capacity to understand or make decisions due to metabolic encephalopathy (a condition where brain dysfunction results from a systemic metabolic problem). The H&P indicated Resident 1 was ventilator dependent. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/16/25, the MDS indicated Resident 1 had adequate hearing, with no speech. Resident 1 had functional limitation in range of motion (ROM, refers to the full movement potential of a joint, encompassing the extent to which a joint can be moved in different directions) with impairment to both upper and lower extremities. Resident 1 was dependent on oral hygiene, toileting, showers, dressing, and personal hygiene. The MDS indicated Resident 1's weight was 136 pounds (lbs. a unit of measurement). During a review of Resident 1's care plan titled [Resident 1] is at risk for unidentified pain/discomfort due to resident's inability to communicate/cognitive impairment, dated 3/21/2025, the care Residents Affected - Few Page 1 of 5 055764 055764 08/08/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan interventions included handling resident gently while providing care and provide non-pharmacological interventions. During a review of Resident 1's care plan titled [Resident 1] is at risk for further decline in activities of daily living (ADL's) and development of contractures, dated 3/21/2025, the care plan indicated to provide rehab (rehabilitation) treatment or RNA program as ordered to minimize decline in joint mobility status and/ or maintain mobility. During a review of Resident 1's care plan titled potential for injury from tremors and involuntary movements due to Parkinson's Disease, dated 3/21/2025, the care plan indicated to notify the physician if involuntary movements increase. During a review of Resident 1's care plan titled [Resident 1] is at risk for increased contractures to the bilateral upper extremity (BUE), dated 6/5/2025, the care plan indicated to maintain joint mobility and ROM in BUE. The care plan interventions indicated to do passive range of motion (PROM the movement of a joint through its full range of motion by an external force, such as a therapist or a machine, without the individual actively contracting their muscles) exercises to the BUE followed by application of bilateral resting hand splints and bilateral elbow extensions splints every day, five times a week. During a review of Resident 1's physician order dated 5/29/2025, the order indicated RNA to do passive range of motion to bilateral upper extremities followed by application of a bilateral resting hand splints (designed to support the hand and wrist in a functional resting position, preventing contractures, reducing pain and swelling) and bilateral elbow extension (the movement of both forearms away from the upper arms, or straightening both elbows simultaneously, to bring the forearm back to the anatomical position) splints every day, five times a week for four hours a day or as tolerated. During a review of Resident 1's facility record titled COC (change in condition)/Interact Assessment Form with effective date of 7/21/2025 timed at 10:30 AM, authored by RN 1, the COC form indicated that at 10 AM, CNA [1] reported to RN 1 that Resident 1's right elbow was flaccid. The COC form further indicated RN 1 assessed Resident 1 and noted the resident's right elbow was flaccid with internal/external rotation, discoloration and warm to touch. The COC form indicated, No indicators of pain or discomfort and RN 1 notified PCP 1 around 10:30 AM and give an order to Monitor. The PCP Form indicated RN 1 would endorse to the next shift. The COC Form indicated the names of RN 1 and LVN 2 as Licensed Nurses Reporting. During a review of Resident 1's care plan titled Right Elbow Flaccid with Internal/External Rotation, developed by RN 1 on 7/21/2025, the care plan goal indicated to minimize risk of complications through interventions. The care plan interventions included immobilizing the right arm, hold Range of Motion (ROM - a type of exercise designed to maintain and improve the flexibility and movement of joints) exercises, handle with care, monitor for swelling and notifying [PCP 1] for any changes. During a review of Resident 1's telephone physician order dated 7/21/2025 timed at 10:30 AM, authored by RN 1, the order indicated that PCP 1 ordered to hold range of motion (ROM) exercises and [elbow extension] splinting to the right arm. During a review of Resident 1's telephone physician order dated 7/22/2025 timed at 11:49 AM, authored by RN 1, the order indicated that PCP 1 ordered, X-ray (a type of medical imaging that uses electromagnetic radiation to create pictures of the inside of the body) [to the] right arm, one time only, for [right] elbow flaccid [with] internal [and] external rotation for 2 days [duration]. During a review of Resident 1's Documentation Survey Report for 7/1/25 to 7/30/25, the Report indicated that RNA provided PROM exercises to Resident 1's BUE for five minutes on 7/21/25 and 7/25/25.During a review of Resident 1's Documentation Survey Report for 7/1/25 to 7/30/25, the Report indicated CNA provided ROM to Resident 1 on 7/21/25, 7/22/25, and 7/23/25. During a review of Resident 1's facility records titled COC/Interact Assessment Form with effective date of 7/24/2025 timed at 5:27 PM, authored by RN 3, the COC form indicated RN 3 received Resident 1's X-ray result that indicated Acute appearing fracture of 055764 Page 2 of 5 055764 08/08/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the humerus. The COC Form indicated RN 3 notified PCP 1 and ordered to transfer to the GACH for evaluation. During a review of Resident 1's telephone physician order dated 7/24/2025 timed at 4:09 PM, the order indicated May resume all previous orders. During a review of Resident 1's facility record titled IDT (interdisciplinary team - a group of people with different functional expertise working toward a common goal)-Narrative-Other Concerns, with an effective date of 7/25/2025, the IDT form indicated the IDT Conference was conducted secondary to [Resident 1's] right humerus fracture. The IDT form indicated IDT met to discuss resident's right humerus fracture. On 7/21/2025, resident [was] noted with right elbow flaccid with internal/external rotation and discoloration, warm to touch, with no signs of pain or discomfort noted. [PCP 1] was notified of [the] resident's condition and gave an order to hold ROM exercises and splinting to [the] right arm and monitor. On 7/22/2025, PCP 1 was updated of [the] resident's right arm condition due to no improvement. [PCP 1] gave new order for right arm X-ray which was scheduled for 7/23/2025. X-ray result [was] received on 7/24/2025 showing right humerus fracture. [PCP 1] was notified of the X-ray result and gave order to transfer to the [GACH] for evaluation. On 7/24/2025, [Resident 1] returned from the [GACH] with new orders . for right arm sling . and follow up with [orthopedic physician]. During a review of the facility's investigation titled Interview Form indicated the following handwritten interview statements with dates from 7/24/2025 to 7/27/2025, from facility staff as interviewed by the Director of Nurses (DON): The DON interview with RN 1 documented on 7/24/2025, indicated on 7/21/2025 at around 10 AM [7 AM to 9 PM shift], RN 1 and LVN 2 went to assess Resident 1's flaccid right arm after staff [CNA 1] report. RN 1 reported to PCP 1 and PCP 1 ordered to monitor, hold Restorative Nurse Assistant (RNA) exercises and splinting on the affected arm. RN 1 indicated in the interview form that she reported resident 1's flaccid right arm to the licensed nurses scheduled on the 3 PM to 11 PM shifts and 11 PM to 7 AM shifts on 7/21/2025. RN 1 further indicated in the Interview Form that the RN of the 11 PM to 7 AM shift (7/22/2025) conducted more observation and updated PCP 1 and PCP 1 gave an order for X-ray of the right forearm, humerus, and elbow. The X-ray was completed on 7/23/2025 and the X-ray result was received on 7/24/2025. The DON interview with LVN 2 documented on 7/24/2025, indicated that on [7/21/2025] she notified RN 1 of Resident 1's right arm. LVN 2 stated RN 1 took a video recording of Resident 1's right arm and send it to PCP 1 through text message. LVN 2 stated PCP 1 ordered For monitoring only. LVN 2 indicated in the Interview Form that she asked the OTA 1 to evaluate Resident 1's right arm. LVN 2 indicated in the Interview Form that OTA 1 heard a clicking sound [to the right arm] and reported OTA 1's evaluation to RN 1. The DON interview with LVN 3 documented on 7/24/2025, indicated that during the morning shift (7 AM to 3 PM), CNA 1 approached LVN 3 and reported that [Resident 1] does not look right and the arm did not look the usual way it looked. LVN 3 indicated in the Interview Form that Resident 1's right arm was normally stiff and contracted so she informed RN 1 to have OTA 1 look at Resident 1's right arm. LVN 3 indicated in the Interview Form that OTA 1 went to see Resident 1 and informed RN 1 of her recommendations. The DON interview with CNA 1 documented on 7/24/2025 indicated that on 7/21/2025, he noticed Resident 1's right arm was more loose, more flexible and the patient gown was easier to remove and put on. CNA 1 indicated in the Interview Form that RN 1, LVN 2 and LVN 3 went to Resident 1's room to assess the resident and stated to be extra careful in handling the resident. CNA 1 indicated he used the mechanical lift that day to transfer the resident from the bed to the shower bed (a specialized piece of equipment designed to facilitate safe and efficient bathing for residents who are unable to use a traditional shower or tub). The form indicated CNA 1 called the Respiratory Therapist (RT 1) to assist him with the resident. The DON interview with RT 1 documented on 7/25/2025, indicated CNA 1 took Resident 1 to the Shower Room on 7/21/2025 055764 Page 3 of 5 055764 08/08/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during the AM shift and he assisted CNA 1 with the resident's tracheostomy tube (a tube inserted to the trachea [windpipe] often necessary when a person needs long-term mechanical ventilation [supply of air to the lungs] due to breathing difficulties or respiratory failure). The form indicated RT 1 noticed Resident 1's right arm was swollen and informed CNA 1 to report to the licensed nurse, but CNA 1 informed him the licensed nurses already know. The DON interview with RNA 1 documented on 7/25/2025, indicated LVN 2 informed RNA 1 that something was wrong with Resident 1's right arm during the morning shift (7 AM-3 PM) of 7/21/2025. The form indicated LVN 2 assisted RNA 1 to put the resident's gown over his right shoulder and was told not to apply elbow [extension] splinting. The form indicated that RNA 1 stated observing Resident 1's right arm was loose and not hard and stiff as before. The DON interview with LVN 1 documented on 7/27/2025, indicated that LVN 1 worked during the night shift (11 PM to 7 AM- 7/19/2025) prior to 7/21/2025. The form indicated Resident 1 did not show any pain and checked blood pressure in Resident 1's right wrist and did not observe any change on the resident's right arm. The DON interview with LVN 4 documented on 7/29/2025, indicated that on 7/22/2025, it was endorsed to him that Resident 1's right arm was Moving and it was not like before, before it was stiff. The form indicated LVN 4 reported to RN 1 and stated RN 1 informed him PCP 1 ordered to monitor. During a review of Resident 1's record titled Multidisciplinary Progress Record dated 8/1/2025, the Progress Record indicated a handwritten note from the orthopedic physician. The Progress Record indicated Right proximal . humerus shaft fracture angulated 25 degrees. Not pathologic (something that is related to or caused by disease, or that deviates from the normal, healthy state), but understandable. Immobilize for two months . During a concurrent observation and interview on 8/7/2025 at 10 AM Resident 1 was observed with his right arm immobilized with an arm sling. Resident 1's left arm was contracted and had a splint. Resident 1's BLE were both contracted and a pillow was placed in between the knees. Restorative Nursing Aide (RNA) 1 stated she and RNA 2, providing 2-person assist to reposition Resident up in bed, with the respiratory therapist at the bedside. RNA 1 stated she just provided exercises for to Resident 1's LUE and BLE, and prior to all exercised, Resident 1 was medicated with pain medication. During an interview on 8/7/2025 at 11:30 AM, Registered Nurse (RN) 1 stated Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 2 told her about Resident 1's arm, I assessed resident and you can do a lot movement than normal, it did not look bruised, little redness (usually red though), no swelling. RN 1 stated she reported Resident's arm to Physician 1 and was given orders to monitor and discontinue range of motion on the right arm. Resident 1 then required to be a three-person assist in which he was initially a 2 person assist and was instructed to not move Resident 1 too much. RN 1 stated the previous shift did not mention anything about Resident 1's right arm. During an interview on 8/7/25 at 5:50 PM with PCP 1, PCP 1 stated Resident 1's right shoulder looked deformed and since there was no evidence of trauma or fall, PCP 1 only ordered for Resident 1's right arm to be immobilized and monitored. PCP 1 stated he did not order an X-ray right away since Resident 1's right arm was not swollen and did not look like there was a fracture or trauma since Resident 1 did not have a fall. PCP 1 stated only ordering an X-ray because an unnamed nurse informed PCP 1 that Resident 1's shoulder looked deformed. PCP 1 could not state the date of when the order for an X ray was ordered. During a concurrent interview and record review on 8/7/25 at 6:45 PM with the DON, Resident 1's care plan was reviewed. The DON stated immobilized meant do not make it move. The DON stated resident care plans must be specific, and for Resident 1 the care plan should indicate to immobilize Resident 1's right arm with a sling. During a telephone interview on 8/13/25 at 8:59 AM, LVN 2 stated on 7/21/25 that she called OTA 1 to assess Resident 1's right arm since Resident 1 was always contracted and always had his right arm close to his body, 055764 Page 4 of 5 055764 08/08/2025 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but on 7/21/25 Resident 1's right arm was more on the bed, which was not Resident 1's usual. During a telephone interview on 8/13/25 at 9:08 AM with RNA 1, RNA 1 stated conducting Resident 1's RNA exercises Monday through Friday for approximately 12 to 15 minutes, as Resident 1 tolerated. RNA 1 stated Resident 1 was really contracted to both upper extremities prior to 7/21/2025. RNA 1 stated the morning of 7/21/2025, RNA 1 was informed by an unnamed nurse to not touch Resident 1's right arm. RNA 1 stated the last time RNA exercises was performed on Resident 1's right arm was on 7/18/2025. During a telephone interview on 8/13/25 at 11:48 AM with OTA 1, OTA 1 stated on 7/21/25 she was asked by LVN 2 to assess Resident 1's right arm because Resident 1's arm looked funny. OTA 1 stated Resident 1's right arm was flaccid and loose and that the internal and external rotation was not tight and was floppy. OTA 1 stated when she touched Resident 1's upper arm and placed OTA 1's right hand on Resident 1's forearm, OTA 1 felt and heard a popping sound. OTA 1 stated she placed a pillow under Resident 1's arm and left the room and told RN 1 that Resident 1's arm felt weird, floppy and flaccid and did not feel tight. OTA 1 stated she informed RN 1 to call PCP 1 to recommend performing an X-ray, however OTA 1 stated RN 1 informed her that PCP 1's order was to only observe and report. OTA 1 stated any further passive movements of Resident 1's right arm should not be performed due to the right arm being flaccid, to avoid a further injury. OTA 1 stated immobilization of the extremity is needed as a precaution to prevent further injury to the resident's right arm. During a review of the facility's Policy and Procedure (P&P) for Care Plans, Comprehensive Person- Center, revised 03/2025, the P&P indicated each residents' comprehensive person-centered care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. 055764 Page 5 of 5