Health inspection·February 20, 2026

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 four sampled residents (Resident 1), who was at risk for skin breakdown, was provided standards of quality care and services while using a low air loss mattress (LALM - a specialized therapeutic support surface that uses a constant flow of air through micro-vents to reduce skin moisture and heat, preventing and treating Stage I-IV pressure ulcers) As a result, Resident 1 had an alteration of skin and a reopening of the right trochanter (thigh bone) fragile scar tissue. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included sepsis, contracture of right and left knee, and muscle weakness. During a review of Resident 1's History and Physical (H&P) dated 12/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary dated 12/4/2025, the Summary indicated a physician order for LALM set according to resident's weight every shift for wound management. During a review of Resident 1's Weights and Vital's Summary dated 2/16/2026 at 3:25 PM, the Summary indicated Resident 1's weight was 88 pounds (lbs. a unit of measurement). During a review of Resident 1's Treatment Administration Record (TAR) dated 2/2026 the TAR indicated on 2/17/2026 during the day shift, Resident 1's LALM was set according to resident's weight. During a review of Resident 1's active care plans for alteration in skin/integrity, actual presence of right trochanter fragile scare tissue, dated 12/4/2025, the care plan indicated an intervention for the low air loss mattress to be set according to resident's weight. During a review of Resident 1's active care plans for at risk for pressure ulcers( injuries to skin and underlying tissue resulting from prolonged pressure, friction, or shear), risk for developing pressure sore and other types of skin breakdown dated 12/31/2025, the care plan indicated an intervention for the low air loss mattress to be set according to resident's weight. During a review of Resident 1's COC (Change of Condition)/Interact Assessment Form (SBAR) dated 2/13/2026, the COC indicated Resident 1 was noted with change in skin condition during routine treatment. The SBAR indicated the right trochanter area observed to be reopened at site of previous fragile scar tissue, small open area noted, no bleeding, surrounding skin fragile, no foul odor and drainage minimal noted. The SBAR indicated measurements were obtained and documented in the wound record. The SBAR indicated Resident 1 was non-verbal, alert, contracted and unable to verbalize pain, facial expression and body movement was monitored during assessment with no acute distress noted. The SBAR indicated the Wound Physician (MD) was notified regarding Resident 1's change in condition and a new order was received to Cleanse with normal saline (NS), pat dry, apply Santyl, and cover with foam dressing for 30 days. During a review of Resident 1's Skin Issues document dated 2/18/2026, the document indicated Resident 1 had a pressure ulcer/injury to rear right trochanter (Hip) which was a stage 1 pressure ulcer/injury (non-blanchable erythema of intact skin). The document indicated the pressure ulcer/injury was in-house acquired with a length of 1 centimeters (cm, unit of Residents Affected - Few Page 1 of 2 055764 055764 02/20/2026 Whittier Pacific Care Center 7716 S Pickering Avenue Whittier, CA 90602

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few measure) and width of 4 cm. The document indicated Resident 1's pressure ulcer/injury had no undermining, no tunneling, light exudate amount that was serosanguineous (mixture of serous and sanguineous fluid), typically pale, red, no watery exudate odor, 100% superficial, surrounding tissue was fragile, scarring, no induration, and no edema. During an observation in Resident 1's room on 02/17/2026 at 2:38 PM, Resident 1 was observed resting in bed with eyes closed. Resident 1 was observed using a LALM and was set to 120 pounds (lbs, unit of measure). During a concurrent observation and interview in Resident 1's room on 2/17/2026 at 2:48 PM, treatment nurse (TN) 1 stated the LALM should not be set to exceed the resident's own weight because it was designed to work in accordance with the resident's current weight. TN 1 stated going over the resident's weight makes the mattress harder and it affects the wound healing since the surface was harder. TN 1 stated licensed nurses (LN) adjusted the setting on the LALM. TN 1 stated the LALM setting was usually check by LVNs and changed according to resident's current weight. TN 1 stated the LALM was for skin and wound management and could assist with the prevention of further wounds. TN 1 stated the LALM for Resident 1 should have been set to 80 since that was Resident 1's current weight and 120 was too firm. TN 1 stated when the setting was to high on the LALM, and not set according to the residents' current weight, wounds could become worse from being too stiff. During a concurrent interview and record review on 2/17/2026 at 3:33 PM, Resident 1's TAR for 2/2026 was reviewed. TN 2 stated the LALM setting should be based on the resident's weight. TN 2 stated the LALM simulates repositioning and releases pressure on the other side. TN 2 stated the LALM was a pressure redistribution mattress and offloads pressure on the boney prominences. TN 2 stated Resident 1's weight should be set closest to the setting, if the setting is higher than the resident's weight, the mattress would be firmer in some cases. TN 2 stated the setting of 120 could be too firm for a resident who was 88 lbs. TN 2 stated Resident 1 had a partial reopen of the skin, no redness or maceration, and no foul odors. During an interview on 2/17/2026 at 4:20 PM, the Director of Nursing (DON) stated if the resident was 88 lbs, the LALM setting should be at 80. The DON stated the resident's weight should always be higher than the LALM setting. The DON stated if the LALM setting was higher, it defeats the purpose of redistribution and could fail in offloading the bony prominences. The DON stated a firm mattress due to incorrect weight setting could potentially increase the pressure on the resident's skin. During an interview on 2/17/2026 at 4:55 PM, the Administrator (ADM) stated the facility's policy and procedure (P&P) did not have a specific setting or instruction on how to set the LALM. During a concurrent interview and record review with the ADM on 2/17/2026 at 5:15 PM , the LALM Operator's Manual was reviewed. The ADM stated the operator's manual did not indicate what to set the mattress to. The ADM stated based on the resident's weight of 88 lbs., the LALM setting of 80 would be more appropriate than 120. During a concurrent interview and record review with the DON 2/20/2026 at 11:13 AM, Resident 1's Care Plan for at risk for pressure ulcers dated 12/31/2025 was reviewed. The DON stated Resident 1's care plan indicated an intervention that the low air loss mattress was to be set according to resident's weight. A review of the undated operation manual for Protekt Aire 4000DX/5000DX (LALM) indicated users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional. A review of the facility's P&P titled Support Surface Guidelines dated 9/2013 indicated the P&P was to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated to review the resident's care plan to assess for any special needs of the residents. The P&P indicated redistributing support surfaces are to promote comfort for all bed-or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. 055764 Page 2 of 2