Health inspection·February 17, 2026

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 observation, interview, and record review, the facility failed to provide care and services specific to the needs required for one of two sampled residents (Resident 1) who had a nephrostomy tubes (a thin, flexible tube that is inserted through the skin of the lower back directly into the kidney that is used to drain urine when the normal flow through the ureter to the bladder is blocked or impaired) by failing to: 1.Initiate and revise Resident 1's care plan to indicate actual and preventative measures for nephrostomy tube dislodgement. 2. Conduct an Interdisciplinary Team (IDT a group of professionals from different disciplines who work together to create and update a resident's individualized care plan) meeting to assess the root causes for Resident 1's nephrostomy tube dislodgement. This failure to perform a root cause analysis of Resident 1's recurring nephrostomy tube dislodgement and failure to initiate appropriate, individualized interventions to prevent future dislodgement of Resident 1's nephrotomy tubes, had the potential to result in repeated hospitalizations, increased risk of infection or other complications associated with nephrostomy tube displacement, and a decline in Resident 1's overall health and quality of life. During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including anoxic brain damage (occurs when the brain does not receive oxygenoften from events like cardiac arrest, choking, or drowning- leading to rapid and irreversible damage to brain cells), persistent vegetative state (a prolonged neurological condition in which a person appears awake but completely lacks awareness, cognition, or purposeful response to their environment due to severe brain injury), artificial openings of urinary tract (nephrostomy tubes), pyelonephritis (kidney infection), urinary calculi (kidney stones), and urinary tract infection (UTI- infection in the bladder/urinary tract). During a review of Resident 1's General Acute Care Hospital (GACH) records from 10/8/2025, the records indicated Resident 1 was admitted to the GACH with a chief complaint of percutaneous nephrostomy malfunction and UTI. The notes indicated Resident 1 underwent a right and left nephrostomy tube exchange and given antibiotics. Resident 1 was discharged from the GACH and readmitted to the facility on [DATE] after five days in the GACH. During a review of Resident 1's General Acute Care Hospital (GACH) records from 10/8/2025, the records indicated Resident 1 was admitted to the GACH with a chief complaint of percutaneous nephrostomy malfunction and UTI. The notes indicated Resident 1 underwent a right and left nephrostomy tube exchange and given antibiotics. Resident 1 was discharged from the GACH and readmitted to the facility on [DATE] after five days in the GACH. During a review of Resident 1's untitled Care Plan (CP) revised on 12/17/2025, the CP indicated Resident 1 had an alteration in urinary elimination and was at risk for UTI secondary to use of indwelling catheter (nephrostomy tubes). The CP indicated nursing interventions to secure the left and right nephrostomy tubing with anchors everyday shift to minimize dislodging of catheter. During a review of Resident 1's Change of Condition (COC) on 1/2/2026 at 2:41 PM, the COC indicated RN 2 wrote, Page 1 of 3 055764 055764 02/17/2026 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [Treatment] Nurse notified RN that [Resident 1]'s right nephrostomy tube was dislodged. Upon further assessment, hematuria (blood in the urine) noted in left nephrostomy bag. [Resident 1] has no visible signs of distress noted, breathing even and unlabored, with no facial grimacing noted. During a review of Resident 1's GACH records from 1/2/2026, the records indicated Resident 1 was admitted to the GACH with a chief complaint of UTI and dislodged right nephrostomy tube. Resident 1 underwent a right nephrostomy tube exchange and was given intravenous (IV- given directly into the blood stream) antibiotics. Resident 1 was discharged from the GACH and readmitted to the facility on [DATE] after 13 days in the GACH. During a review of Resident 1's Change of Condition (COC) on 1/24/2026 at 1:40 AM, the COC indicated RN 3 wrote, . During first round change, CNA reported [Resident 1] left nephrotomy tube appears out of place and the urine collection bag was empty. The gauze dressing used to keep the tube in place was off and saturated with urine. On RN observation, the nephrostomy tube was inside stoma (a surgically created opening on the body's surface) but observed to be out of place 13.5 centimeters (cm) out with urine leaking from stoma . MD 1 notified and request made to transfer [Resident 1] for replacement. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 1 was in a persistent vegetative state and fully dependent on staff for all cares including personal hygiene, turning, and repositioning. During a review of Resident 1's Change of Condition (COC) on 1/24/2026 at 1:40 AM, the COC indicated RN 3 wrote, . During first round change, CNA reported [Resident 1] left nephrotomy tube appears out of place and the urine collection bag was empty. The gauze dressing used to keep the tube in place was off and saturated with urine. On RN observation, the nephrostomy tube was inside stoma (a surgically created opening on the body's surface) but observed to be out of place 13.5 centimeters (cm) out with urine leaking from stoma . MD 1 notified and request made to transfer [Resident 1] for replacement. During a review of Resident 1's untitled CP initiated on 1/24/2026, the CP indicated Resident 1 had a change of condition manifested by left nephrostomy tube displacement. The CP indicated nursing interventions to carry out new MD orders to transfer Resident 1 to the GACH for left nephrostomy tube displacement, notify MD and Resident 1's responsible party, provide standard nursing care such as reassurance and alleviate pain or discomfort as needed, and vital signs and pain rating. During a review of Resident 1's untitled CP initiated on 1/24/2026, the CP indicated Resident 1 was transferred to the GACH secondary to left nephrostomy tube displacement. The CP indicated nursing interventions to monitor vital signs, notify MD of any changes in Resident 1's condition, notify responsible party of any changes of resident's condition, position Resident 1 for comfort, and transfer to GACH for evaluation as indicated/ordered. During a review of Resident 1's Change of Condition (COC) 1/26/2026 at 1:05 PM, the COC indicated RN 1 wrote, [1 PM]- [Resident 1] left nephrostomy bag noted with no urine output. MD 1 notified with new order to send resident to [hospital] for exchange. During a review of Resident 1's GACH records from 1/26/2026, the records indicated Resident 1 was admitted to the GACH with a chief complaint of a dislodged left nephrostomy tube and UTI. The records also indicated on 1/27/2026, GACH Physician Assistant (GACH PA) wrote, Patient has had multiple dislodged nephrostomies over the past few months, is paraplegic and bedbound unknown how patient keeps getting dislodged nephrostomies. Patient seen in the emergency room (ER) with a left-sided dislodged nephrostomy, was actually seen at outside hospital [two] to [three] days prior for similar issues. The records indicated Resident 1 underwent a left nephrostomy tube placement on 1/28/2026 and was given antibiotics. Resident 1 was discharged from the GACH and readmitted to the facility on [DATE] after seven days in the GACH. During an interview with RN 2 on 2/17/2026 at 12:51 PM, RN 2 stated Resident 1 had recurring issues with his nephrostomy tubes becoming dislodged. RN 2 further stated the nephrostomy 055764 Page 2 of 3 055764 02/17/2026 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tubes were stitched in place and dressings were used to further anchor down and secure the tubes from dislodgement, but she did not know why Resident 1's nephrostomy tubes continued to become dislodged. During a concurrent interview and record review with RN 2 on 2/17/2026 at 1 PM, Resident 1's Care Plans were reviewed. RN 2 stated the care plan was not revised to include new interventions to prevent the nephrostomy tubes from becoming dislodged again. RN 2 further stated it was important to keep Resident 1's care plan updated and ensure interventions were in place to maintain Resident 1's safety and reduce the risk of recurring dislodgement. During an interview with the Director of Nursing (DON) on 2/17/2026 at 4:09 PM, the DON stated the interdisciplinary team did not have a meeting regarding Resident 1's recurring nephrostomy tube dislodgements. The DON further stated a root cause analysis was not done and it was never determined why Resident 1's nephrostomy tubes continued to become dislodged. During a concurrent interview and record review with the DON on 2/17/2026 at 4:15 PM, Resident 1's care plans were reviewed. The DON stated Resident 1's care plan was not revised with new and individualized interventions to prevent Resident's nephrostomy tubes from becoming dislodged. The DON stated it was important to have IDT meetings and determine the cause of Resident 1's recurring nephrostomy tube dislodgements to prevent future dislodgements and hospitalizations. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered revised 3/2023, the P&P indicated the following:The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and condition.Care plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.When possible, interventions address the underlying sources of the problem areas, not just symptoms or triggersAssessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan:When there has been a significant change in the resident's conditionWhen desired outcome is not metWhen the resident has been readmitted to the facility from a hospital stayAt least quarterly, in conjunction with the required quarterly MDS assessment. 055764 Page 3 of 3