Health inspection·August 3, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there was no care plan in Resident 11's clinical record to address the use of bilateral heel protectors. RN 1 indicated there should have been a care plan created on the use of heel protector to serve as guidance for the staff on how to care for the resident using heel protectors. A review of the facility's policy and procedure titled Care Plan, Comprehensive Interdisciplinary revised 1/2018 indicated a comprehensive interdisciplinary care plan will be developed for each resident based on his/her comprehensive assessment. The care plan includes measurable objectives and time frames to meet the resident's medical, nursing, mental, psychosocial and developmental needs. The plan of care is updated/reviewed/revised with change in needs or care, weekly, quarterly and with any significant change of condition. Event ID: Facility ID: 555589 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to modify the care plan for one of 12 sampled residents (Resident 2) to reflect the use of specific medications ordered, Xopenex (medication that relaxes muscles in the airways and increases air flow to the lungs) and Pulmicort (indicated for the maintenance treatment of asthma and as prophylactic [preventative] therapy in children 12 months to eight years of age) as interventions to address resident's ineffective breathing and airway. This deficient practice had the potential for residents not to receive specific interventions to address needs, which can result in well-being decline. Findings: A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of hydrocephalus (condition characterized by excess fluid build-up in fluid-containing cavities of the brain). A review of the Minimum Data Set (standardized assessment and care screening tool), dated 6/23/19 indicated that Resident 2 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 2 was totally dependent on the staff for bed mobility, transfer, locomotion, gastrostomy tube feeding (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration), toileting, personal hygiene, and bathing. On 8/1/19 at 8:10 p.m., Resident 2 was observed awake in bed. A review of Resident 2's physician's order indicated the following: 1. Xopenex nebulization (medication administration via inhalation) solution 0.63 milligrams (mg)/milliliters (ml) via mask every six hours for wheezes and shortness of breath (ordered on 6/17/19) 2. Pulmicort 0.5 mg hand held nebulizer (HHN) twice a day (ordered on 7/18/19). A review of Resident 2's care plan titled, Potential for Ineffective Breathing and Airway, dated 6/17/19, indicated staff interventions were to visually check resident every hour, assess respiration and breath sounds every four hours and as needed, and suction tracheostomy as needed. The care plan did not include the use of specific medications, Xopenex and Pulmicort. On 8/3/19 at 10:25 a.m., during a concurrent record review and interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 verified Resident 2 had an order for Xopenex every six hours for wheezing and shortness of breath and shortness of breath and Pulmicort twice a day. LVN 1 stated the care plan did not and should have indicated the specific medications on the care plan. LVN 1 stated that this was important because the care plan is the resident's treatment, which will assist the staff in providing care. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, revised 1/2018, indicated that a comprehensive interdisciplinary care plan will be developed for each resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm based on his/her comprehensive assessment. P&P indicated that it takes into consideration all problems/needs identified by the various disciplines and the resident/family in the assessment process, including physician's medical plan of treatment. It also indicated that the plan of care is reviewed weekly by the licensed nurse with weekly summary, and is revised/updated as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the clinical record indicated Resident 71 was admitted to the facility on [DATE] with diagnoses that included Menke's disease (disorder characterized by fragile, twisted hair, growth delay, and progressive deterioration of the brain, due to an error in copper transport that results in copper deficiency). A review of Resident 71's physician's order dated 8/1/19 at 11:19 a.m., indicated Tube Feed Formula Elecare Jr. at 60 milliliters (ml) per hour for 20 hours plus water flush 20 ml every 4 hours via Gastrostomy Tube (GT-creation of an artificial external opening into the stomach for medication and nutritional support). On 8/2/19 at 9:45 a.m., Resident 71 was observed in bed sleeping with GT feeding of Elacare Jr ongoing via GT pump at 60 ml per hour. The feeding bottle was hung on a feeding pole. One wheel was detached from the base of the feeding pole while the GT feeding was ongoing. The feeding pole was observed unstable. Licensed Vocational Nurse 2 (LVN 2) confirmed the feeding pole was unstable. LVN 2 stated it was unsafe for the resident that the feeding pole where the feeding formula was hung was unsteady. LVN 2 stated she will call maintenance department to fix the device immediately. On 8/3/19 at 11:49 a.m., an interview was conducted with the facility's Supervising Engineer (SE) who stated any reported broken equipment in patient care areas are removed from the unit and replaced. SE stated if the equipment cannot be fixed then it would be replaced. SE stated it is the unit staff's responsibility to report immediately to maintenance department any defective equipment. SE stated if a feeding pole is unsteady, it should not be used since it could topple over and cause injury to the resident. A review of the facility's policy and procedure titled Safety Measures for Pediatric Residents revised 9/2010 indicated all caregivers are to observe the safety measures for pediatric residents in order to provide a safe and secure environment for pediatric residents. Based on observation, interview, and record review, the facility failed to ensure two of nine sampled residents (Residents 1 and 71) were free of accident hazards: a. Resident 1, who has a diagnosis of seizure disorder (uncontrolled electrical activity in the brain) did not have a padded side rail in place on 8/1/19, as indicated on the care plan. b. Resident 71's gastrostomy tubing (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) pole was unsteady while G-tube feeding was ongoing. This deficient practice had the potential to result in an injury and harm to the residents. Findings: a. A review of the admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis of encephalopathy (disease, damage, or malfunction of the brain manifested by an altered mental state that is sometimes accompanied by physical changes). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Minimum Data Set (standardized assessment and care screening tool), dated 7/7/19 indicated that Resident 1 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 1 was totally dependent on the staff for bed mobility, transfer, locomotion, personal hygiene, toileting, gastrostomy tubing (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration), dressing, and bathing. Resident 1's diagnoses included seizure disorder (uncontrolled electrical activity in the brain) and unspecified intellectual disabilities. On 8/1/19 at 8:50 p.m., during concurrent observation and interview with certified nurse assistant 1 (CNA 1), Resident 1 was observed sleeping with bilateral side rails up. CNA 1 concurred that the right side rail was padded, but the other pad was not in place and was not covering the entire left side rail. The pad on the left side rail was observed to have three straps, but only one strap was attached to the uppermost part of the side rail. CNA 1 stated that Resident 1 tends to move his arms so might have pushed the pad up and uncovered the left side rail. CNA 1 stated that all the straps on the pad should have been tied to the side rail and should be covering the side rail for safety and to prevent injury. A review of Resident 1's Fall Risk Assessment, dated 6/2/19, indicated a score of 14 (a score of eight or above represents high risk). A review of Resident 1's care plan titled, Ineffective Safety Related to Seizure Disorder, reevaluated 6/9/2019, indicated staff interventions included were to visually check resident every hour and as needed, pads on side rails, bed in lowest position when not in direct contact and supervise activities as tolerated. On 8/2/19 at 6:23 p.m., during concurrent record review and interview with Registered Nurse 2 (RN 2), RN 2 confirmed that Resident 1 was high risk for falls, as indicated on the Fall Assessment. RN 2 stated that according to the care plan, the side rails should be padded to prevent injuries due to Resident 1's diagnosis of seizure disorder and spasms of the upper and lower extremities. A review of the facility's policy and procedure titled, Safety Measures for Pediatric Residents, revised 9/2010, indicated that all caregivers are to observe the safety measures for pediatric residents in order to provide safe and secure environment for pediatric residents. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, revised 1/2018, indicated that a comprehensive interdisciplinary care plan will be developed for each resident based on his/her comprehensive assessment. It indicated that a care plan includes measurable objectives and time frames to meet the resident's medical, nursing, mental, psychosocial and developmental needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding at 165 cubic centimeter (cc)/hour (hr), as indicated on the physician's order, to one of 12 sampled residents (Resident 15). This deficient practice had the potential to affect resident's nutritional caloric intake, which can result in significant weight loss. Findings: A review of the admission Record indicated that Resident 15 was admitted to the facility on [DATE] with diagnosis of unspecified condition of the brain. A review of the Minimum Data Set (standardized assessment and care screening tool), dated 7/14/19 indicated that Resident 15 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 15 was totally dependent on the staff for bed mobility, transfer, locomotion, G-tube feeding, toileting, personal hygiene, and bathing. Resident 15's diagnoses included chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and anemia (lowered ability of blood to carry oxygen resulting in feeling tired and shortness of breath). A review of Resident 15's physician's order, dated 4/15/19, indicated Jevity1.5 calorie (cal) liquid. Give 160 milliliters (ml) via G-tube five times a day for nutrition via pump over one hour (hr) with 280 ml water flush five times a day. Resident 15's G-tube order was changed on 7/25/19 to increase tube feeding rate to 165 ml/hr. On 8/1/19 at 8:52 p.m., Resident 15 was observed in bed with G-tube running at 160 ml/hr. Resident 15's G-tube bottle label indicated a rate of 165 ml/hr. On 8/1/19 at 8:56 p.m., during a concurrent observation and interview with Registered Nurse 3 (RN 3), she acknowledged that Resident 15's G-tube feeding was running at 160 ml/hr. RN 3 stated that Resident 15's G-tube order was to give it at 165 ml/hr. RN 3 stated will adjust Resident 15's G-tube rate to 165 ml/hr as ordered. On 8/2/19 at 6:57 p.m., during a concurrent record review and interview with RN 2, she stated that Resident 15's G-tube order was to give Jevity 1.2 cal at 165 cc/hr via GT five times a day. RN 2 stated that it was important to give the GT feeding as ordered to prevent resident from losing or gaining weight unnecessarily. RN 2 stated the Dietitian evaluates and provides recommendation for G-tube feeding to meet caloric intake of the patient, which takes into account the resident's height, age, and weight patient. A review of Resident 15's care plan titled, Alteration in Nutrition Related to Inability to Take in Oral Feedings and Fluids, revised on 6/3/19, indicated staff interventions included were to weigh resident monthly, give Jevity1.5 cal liquid at 165 ml via G-tube for nutrition via pump over one hour (hr) with 280 ml water flush five times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Gastrostomy Tube Feeding, revised 2/2015, indicated that nourishment will be provided to all residents with G-tube. It indicated to obtain/verify physician's order for formula, frequency, amount and route. It indicated that if a pump is ordered, to start the pump and adjust setting per physician's order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the psychotropic (any medication capable of affecting the mind, emotions, and behavior) drug regimen for two of six of 12 sampled residents (Residents 2 and 20) included indication for use of the psychotropic medications : a. For Resident 2, there was no specific target behavior for the use of Clonazepam (Klonopin, antianxiety) 0.04 milligrams (mg) via G-tube every eight hours as needed (PRN) for diagnosis of agitation. There was no duration and physician documented rationale for the continued use of PRN Clonazepam, which was ordered since 6/17/19. b. For Resident 20, there was no specific target behavior for the use of Lorazepam (Ativan, antianxiety) 0.6 mg via G-tube every four hours PRN for diagnosis of agitation. There was no duration and physician documented rationale for the continued use of PRN Lorazepam, which was ordered since 3/25/19. This deficient practice had the potential to result in significant adverse (harmful) consequences to the residents. Findings: a. A review of the admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis of hydrocephalus (condition characterized by excess fluid build-up in fluid-containing cavities of the brain). A review of the Minimum Data Set (standardized assessment and care screening tool), dated 6/23/19 indicated Resident 2 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 2 was totally dependent on the staff for bed mobility, transfer, locomotion, gastrostomy tube feeding (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration), toileting, personal hygiene, and bathing. Resident 20 did not exhibit any mood or behavioral symptoms. On 8/1/19 at 8:10 p.m., Resident 2 was observed calm and awake in bed. A review of Resident 2's physician's order, dated 6/17/19, indicated Klonopin (antianxiety) 0.04 milligrams (mg) via G-tube every eight hours as needed (PRN) for diagnosis of agitation. On 8/2/19 at 11:33 a.m., during a concurrent record review and interview with Licensed Vocational Nurse 1 (LVN 1), she acknowledged that Resident 2 has an order for Klonopin for agitation via G-tube every eight hours PRN. LVN 1 stated that Resident 1's indication of agitation for the use of Klonopin should be specified because this can be different from one resident to the other. On 8/3/19 at 10:36 a.m., during concurrent record review and interview with LVN 1, she stated that Resident 2's order for the use of Klonopin did not and should have a duration so the physician can evaluate its use. LVN 1 added that it is important to evaluate psychotropic medication use to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 residents from the side effects, such as lethargy and low blood pressure. Level of Harm - Minimal harm or potential for actual harm On 8/3/19 at 11:25 a.m., during a concurrent record review and interview with the Pharmacist, he acknowledged that Resident 2's physician order, dated 6/17/19, did not have a duration for the use of PRN Klonopin. Residents Affected - Few On 8/3/19 at 11:45 a.m., during a concurrent record review and interview with Registered Nurse 1 (RN 1) , she acknowledged that physician's most recent progress notes dated 7/29/19, did not indicate the use of Klonopin for Resident 2's treatment plan. A review of Resident 2's care plan, dated 6/17/19, indicated the use of Klonopin PRN for agitation. Staff interventions included were to assess level of consciousness or behavior every shift and as needed, watch for side effects, and notify physician of changes in condition. b. A review of the admission Record indicated that Resident 20 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). A review of the Minimum Data Set (standardized assessment and care screening tool), dated 6/23/19, indicated that Resident 20 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 20 was totally dependent on the staff for bed mobility, transfer, locomotion, personal hygiene, toileting, gastrostomy tubing (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration), dressing, and bathing. Resident 20 did not exhibit any mood or behavioral symptoms. On 8/1/19 at 8:15 p.m., Resident 20 was observed in bed awake and calm. A review of Resident 20's physician's order, dated 3/25/19, indicated Lorazepam (Ativan, antianxiety) 0.6 milligrams (mg) via G-tube every four hours as needed (PRN) for diagnosis of agitation. On 8/2/19 at 7:25 p.m., during concurrent record review of the order summary report and interview with Registered Nurse 2 (RN 2), RN 2 acknowledged that Resident 20 has an order for Lorazepam 0.6 mg via G-tube every four hours PRN for agitation. RN 2 stated that Resident 20's manifestation for agitation included crying and being jittery. RN 2 stated that Resident 20 last received Lorazepam PRN on 6/26/19 for agitation, but was not effective because resident's heart rate was 145 beats/minute. RN 2 also stated that Lorazepam order does not have a stop date. RN 2 stated that it was important to have duration for the use of Lorazepam so the physician can reevaluate its use. On 8/3/19 at 11:49 a.m., during a concurrent record review and interview with RN 1, she acknowledged that physician's most recent progress notes, dated 7/29/19, did not indicate use of Lorazepam for Resident 20's treatment plan. A review of Resident 20's care plan, dated 8/2/19, indicated the use of Ativan PRN for agitation. Staff interventions included were to assess level of consciousness or behavior every shift and as needed, watch for side effects, and notify physician of changes in condition. On 8/3/19 at 5:40 p.m., during concurrent policy review and interview with the Director of Nursing (DON), she stated that the facility's policy on psychotropic medications is discussed in the facility's policy titled, Chemical Use of Restraints. DON stated that the policy would need to be updated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 to reflect the regulations regarding required duration for PRN medications. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Chemical Use of Restraints, revised 9/2010 and reviewed 1/2018, indicated that chemical restraint is a drug or medication that is used as a restriction to manage patient's behavior. Chemical restraint medications include, but are not limited to, antianxiety, antipsychotics, hypnotics and antidepressants. It indicated that chemical restraint order must include name of drug, dose, frequency and indication for use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare and store food in accordance with professional standards of food service safety. Residents Affected - Some This deficient food handling practices had the potential to result in food borne illnesses (ingestion of contaminated food or beverages) for the residents. Findings: a. On 8/1/19 at 7:05 p.m., during an initial tour of the kitchen with Kitchen Supervisor (KS), the following were observed: - Nine pieces of breaded eggplant in Ziploc bag, dated 4/1/19 with use by date of 7/1/19. - Nineteen breaded chicken legs in one Ziploc bag, not in original container was unlabeled. There was no item name and no use by date on the Ziploc bag. - One bag of chicken popcorn dated 6/11/19 with use by date of 7/11/19. A concurrent interview was conducted with KS who stated the above items needed to be thrown away to prevent serving food outside of the use by date. KS stated We have to label with item name and use by date in all food items. When the food item is out of the original box, the expiration date should also be written on the container or plastic bag. KS stated the expiration date is the use by date on the food label. A review of the facility's policy and procedure titled Food Storage revised 9/1/11 indicated all foods are to be covered, labeled and refrigerated. Items are dated and a clear identification (product label or written label) is placed on container. Expiration dates to be adhered to and items discarded if expiration date is reached and items has not been used. b. On 8/2/19 at 5:48 p.m., a follow up visit of the kitchen was conducted. There was no documented evidence that the food temperature was monitored for Resident 6 food tray prior to serving. There was no log of food temperatures to ensure the food meets the required temperature for the resident's safety. A concurrent interview was conducted with the Kitchen Supervisor(KS) who confirmed only Resident 6 from the Pediatric Sub Acute Unit gets food from the kitchen. A concurrent interview was conducted with Registered Dietitian who confirmed there was no documented evidence that the food temperatures for Resident 6 were logged. RD stated, We need to get the temperature of the food before serving to ensure it is meeting the right temperature for food safety to prevent food borne illnesses. We do not have a log. We should have a temperature log to make sure the correct temperatures are met before serving the food to Resident 6. On 8/2/19 at 5:55 p.m., Dietary Director (DD) confirmed there was no food temperature log for Resident 6. DD indicated this practice needs to be corrected immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Food Production, revised 4/2018 indicated the purpose of the policy is to identify production procedures to ensure safe, sanitary, food preparation methods. Hot food is checked for proper temperature with a thermometer. Foods need to be with appropriate serving temperatures. Any foods not within appropriate temperature are removed and brought to proper temperatures before serving. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of the clinical record indicated Resident 71 was admitted to the facility on [DATE] with diagnoses that included Menke's disease (disorder characterized by fragile, twisted hair, growth delay, and progressive deterioration of the brain, due to an error in copper transport that results in copper deficiency). Residents Affected - Few A review of Resident 71' physician's order dated 7/31/19 indicated Budesonide 0.5 mg Hand Held Nebulizer twice a day. On 8/2/19 at 9:45 a.m., Resident 71 was observed in bed sleeping. A breathing treatment bag was hung at bedside. The breathing treatment bag was not labeled. Licensed Vocational Nurse 2 (LVN 2) confirmed the bag was unlabeled. LVN 2 stated the bag should be labeled to ensure the bag belongs to the right patient to prevent infection. On 8/2/19 at 9:47 a.m., an interview was conducted with Registered Nurse 4 (RN 4) who confirmed the breathing treatment bag was unlabeled. RN 4 stated staff needs to label the breathing treatment bag to prevent cross contamination; making sure the equipment belongs to the right patient. On 8/3/19 at 4:15 p.m., an interview was conducted with Respiratory Therapist 1 (RT 1) who stated The delivering device for breathing treatment is in the bag by the resident's bedside. The bag should be labeled. The RT should be labeling and making sure the bag is properly labeled to identify the patient and prevent cross infection among patients. A review of the facility policy titled Respiratory Equipment Handling revised 9/2018 indicated the policy is to ensure that there is sufficient type and quantities of equipment to provide appropriate therapy, and the equipment being used will not be a source of transmission or reservoir of pathogenic organisms. On 8/3/19 at 5:36 p.m., during a concurrent policy record review and interview with the director of nursing, she stated the respiratory therapy policy indicated that the equipment being used will not be a source of transmission or a reservoir for pathogenic organisms. DON stated the breathing treatment tubing should be kept inside a plastic bag and labeled to prevent cross-contamination. Based on observation, interview and record review, the facility failed to implement its policy and procedure on infection control for two of 12 sampled residents (Residents 2 and 71). 1. Resident 2's breathing treatment tubing was found on top of resident's toy at bedside on 8/1/19. 2. Resident 71's breathing treatment bag was unlabeled. This deficient practice has the potential to cause the spread infection to the residents and staff. Findings: a. A review of the admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis of hydrocephalus (condition characterized by excess fluid build-up in fluid-containing cavities of the brain). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Minimum Data Set (standardized assessment and care screening tool), dated 6/23/19 indicated that Resident 2 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 2 was totally dependent on the staff for bed mobility, transfer, locomotion, gastrostomy tube feeding (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration), toileting, personal hygiene, and bathing. Resident 20 did not exhibit any mood or behavioral symptoms. On 8/1/19 at 8:10 p.m., Resident 2 was observed calm and awake in bed. On 8/1/19 at 8:12 p.m., during a concurrent observation and interview with Registered Nurse 3, (RN 3), a breathing treatment tubing was found on top of Resident 2's toy on the table (side of the bed). RN 3 stated that the tubing should be in a bag for identification purpose, and to prevent contamination. A record review of the facility policy and procedure titled, Respiratory Therapy, revised on 9/2018, indicated that the equipment being used will not be a source of transmission or a reservoir for pathogenic organisms. On 8/3/19 at 5:36 p.m., during a concurrent policy record review and interview with the director of nursing (DON), she stated that the Respiratory therapy policy indicating that the equipment being used will not be a source of transmission or a reservoir for pathogenic organisms meant that the breathing treatment tubing should be kept inside a plastic bag and labeled to prevent cross-contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 12 sampled residents (Resident 6 and Resident 16) were screened for the use of antibiotics (medications to treat infection) using the McGeer Criteria for Infection Surveillance Checklist for the month of June 2019, per facility policy. Residents Affected - Some This deficient practice had the potential to result in the development of antibiotic-resistant organisms (not effective to treat infection), from unnecessary or inappropriate antibiotic use. Findings: a. A review of the clinical record indicated Resident 6 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included quadriplegia (paralysis of all four limbs). A review of Resident 6's physician's order dated 6/17/19 indicated Levaquin 500 milligrams (mg), one tablet every 24 hours, through Gastrostomy Tube ( GT- creation of an artificial external opening into the stomach for medication and nutritional support) for tracheitis (infection of the trachea [tube or system of tubes that carries air]). Stop Date : 6/26/19. A review of Resident 6's short term care plan for tracheitis dated 6/17/19 indicated to administer Levaquin antibiotic as ordered daily. A review of Resident 6's clinical record did not indicate the McGeer Criteria for Infection Surveillance Checklist was used to screen the resident for appropriateness of the use of antibiotics for the month of June 2019. On 8/3/19 at 4:30 p.m., an interview was conducted with the facility's Director for Infection Control (DIC) and Infection Preventionist Manager (IPM). Both staff confirmed the facility failed to use the Mc Geers Criteria for Infection Surveillance Checklist. Both staff indicated the checklist is used to identify specific criteria in order to screen the residents for appropriate use of antibiotics. Both staff stated each resident receiving antibiotics should be screened using the criteria indicated in the checklist. According to the DIC, the IPM will identify if the resident met the criteria or not based on the sign/ symptoms presented. DIC stated, if the resident does not meet the criteria, the physician needs to be consulted for the appropriateness of the use of antibiotic for the resident. DIC stated, the physician's recommendation should be documented in the resident's clinical record. A review of the facility's policy and procedure titled Criteria for Determining Hospital Acquired Infections, revised 10/2013 indicated the Pediatric Sub Acute Department will follow the definitions of infection for Surveillance in Long Term Care Facilities as per Mc Geer's criteria. A review of the facility's policy and procedure titled Antimicrobial Stewardship Program revised 11/2017 indicated the objective of the policy is to provide guidelines for establishing and maintaining an effective multidisciplinary Antimicrobial Stewardship Program (ASP- rational, systematic approach to the use of antimicrobial agents in order to achieve optimal outcomes). This means using the right agent, at the correct dose, for the appropriate duration in order to cure or prevent infection, while minimizing toxicity and emergence of resistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. A review of the clinical record indicated Resident 16 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included encephalopathy (disease that affects the function or structure of the brain). A review of Resident 16's physician's order dated 6/6/19 indicated Ciprofloxacin 500 milligrams (mg), one tablet every 12 hours, through Gastrostomy Tube ( GT- creation of an artificial external opening into the stomach for medication and nutritional support) for tracheitis (infection of the trachea [tube or system of tubes that carries air]). Stop Date : 6/15/19. A review of Resident 16's short term care plan for tracheitis, dated 6/6/19 indicated to administer Cirprofloxacin 500 milligrams twice a day , GT for 10 days for tracheitis. A review of Resident 16's clinical record did not indicate the McGeer Criteria for Infection Surveillance Checklist was used to screen the resident for appropriateness of the use of antibiotics for the month of June 2019. On 8/3/19 at 4:30 p.m. an interview was conducted with the facility's Director for Infection Control (DIC) and Infection Preventionist Manager (IPM). Both staff confirmed the facility failed to use the Mc Geers Criteria for Infection Surveillance Checklist. Both staff indicated the checklist is used to identify specific criteria in order to screen the residents for appropriate use of antibiotics. Both staff stated each resident receiving antibiotics should be screened using the criteria indicated in the checklist. According to the DIC, the IPM will identify if the resident met the criteria or not based on the sign/ symptoms presented. DIC stated, if the resident does not meet the criteria, the physician needs to be consulted for the appropriateness of the use of antibiotic for the resident. DIC stated, the physician's recommendation should be documented in the resident's clinical record. A review of the facility's policy and procedure titled Criteria for Determining Hospital Acquired Infections, revised 10/2013 indicated the Pediatric Sub Acute Department will follow the definitions of infection for Surveillance in Long Term Care Facilities as per Mc Geer's criteria. A review of the facility's policy and procedure titled Antimicrobial Stewardship Program revised 11/2017 indicated the objective of the policy is to provide guidelines for establishing and maintaining an effective multidisciplinary Antimicrobial Stewardship Program (ASP- rational, systematic approach to the use of antimicrobial agents in order to achieve optimal outcomes). This means using the right agent, at the correct dose, for the appropriate duration in order to cure or prevent infection, while minimizing toxicity and emergence of resistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555589 If continuation sheet Page 17 of 17