Health inspection·March 7, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet professional standards of quality for 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknown length of time. Residents Affected - Few This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause rapid neurologic deterioration and death, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the windpipe), and gastrostomy (a surgically placed device used to give direct access to stomach for feeding, hydration, or medicine) dependence. Patient 2's H&P indicated under the physical examination, Neruo: Encephalopathic (disturbance of brain function) without purposeful movement, hypertonic and spastic. The H&P indicated the plan for respiratory care, Tracheostomy dependent . During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 1:18 p.m., the DIR stated patient 2 sustained a burn injury at the right middle lateral back and right posterior forearm on 1/2/24. The DIR stated Patient was found lying on a ventilator humidifier tube and the WCN noted that Patient 2 was found with blister on the back and right forearm. During an interview with the Wound Care Nurse (WCN) on 3/7/2024 at 2:45 p.m., stated that she was asked to initial a wound consult for Patient 2; found serous exudate intact blisters at Patient 2's right posterior foreman and rupture blister with partial thicken at right lateral back, no one witness what had happened, but facility investigated that the cause from the blister could be from lying on the ventilation heated tubing with unknown time. A review of Patient 2's medical record titled Wound Care Specialist Evaluation notes, dated 1/2/24, the WCN validated that she was consulted on Patient 2 for evaluation of lesions on the right arm (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555589 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 03/07/2024 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)