Health inspection·February 22, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Annual Health Recertification Survey conducted on 1/8/2023 to 1/11/24 and an facility reported incident was investigated during the survey. FRI # CA00876594 Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 47882 Health Facilities Evaluator Nurse:42854 Health Facilities Evaluator Nurse:48905 Health Facilities Evaluator Nurse: 49252 Health Facilities Evaluator Nurse: 48678 Health Facilities Evaluator Nurse: 48903 Health Facilities Evaluator Nurse: 42878 Health Facilities Evaluator Nurse: 42334 Supervising Health Facilities Evaluator Nurse: 43419 Occupationa Therapy Consultant: 41379 Pharmacy Consultant: 49130 Pharmacy Consultant: 31333 Total Resident census: 152 Total Resident Sample: 30 Highest Severity and Scope: E FRI CA00876594 - was unsubstantiated and no deficiency cited.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 02/05/2024 §483.10(a) Resident Rights. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 1 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 2 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility staff failed to promote dignity and respect for one of three sampled residents (Resident 46). Certified Nursing Assistant (CNA) 12 was observed standing next Resident 46, who was seated in a wheelchair, while assisting the resident to eat lunch. This deficient practice violated the resident's rights to maintain and enhanced their selfesteem, self-worth, and the right to be treated with dignity and respect. Findings: A review of Resident 46's Face Sheet indicated a readmission to the facility on 7/26/2022 with diagnoses that included cerebral infraction (refers to damage to tissues in the brain due to a loss of oxygen), dementia (loss of cognitive functioning, thinking, remembering, and reasoning) A review of Resident 46's History and Physical Assessment dated 8/23/2022, indicated Resident 46 does not have the capacity to understand and make decisions. A review of Resident 46's Minimum Data Set (an assessment and screen tool) dated 12/19/2023, indicated Resident 46 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) on eating, oral hygiene, toileting, showers, upper and lower body dressing and personal hygiene. During a concurrent observation and interview on 1/8/2024 at 12:17 PM, Certified Nursing Assistant (CNA 12) was standing next to Resident 46 while assisting the resident to eat during lunch. Resident 46 was sitting in wheel chair. CNA 12 stated she had a chair next to Resident 46's bedside but since it since FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 3 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 46 was no a regular resident assigned to her, she does not sit next to the resident when she assisted the resident to eat. CNA 12 stated when assisting a resident to eat, the staff must be sitting and at eye level with the resident. During an observation and concurrent interview with the Director of Staff Development (DSD) on 1//24 at 12:24 PM, DSD observed CNA 12 standing in front of Resident 46 while feeding her lunch while assisting the resident to eat lunch. DSD stated when assisting residents to eat, the CNA 12 should always be at eye level with the residents and never standing over next to them . A review of facility's policy and procedure titled "Resident Rights-Dignity and Privacy," dated 11/2021 indicated The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 02/05/2024 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 4 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review the facility failed to notify the resident's primary physician for one of one sampled resident (Resident 87) who refused glucose monitoring (a test that measures the amount of sugar in a resident's blood). These failures have the potential to result in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 5 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE decline of Resident 87's medical status which included hypoglycemia (low blood sugar; can cause weakness, confusion, and coma), hyperglycemia (high blood sugar; can lead to blindness and heart problems) and possible hospitalization. Findings:? During a review of Resident 87's Face Sheet, the Face Sheet indicated Resident 87 was admitted to the facility on 8/10/2023, with diagnoses that included Type 2 Diabetes Mellitus (a disease that causes a problem in the way the body uses sugar as a fuel). During a review of Resident 87's History and Physical dated 8/11/2023, the History and Physical indicated Resident 87 has the capacity to understand and make decisions. During a review of Resident 87's Care Plan History revised on 11/26/2023, indicated Resident 87 has episodes of refusing blood sugar checks. The care plan did not indicate alternative measures provided to the resident for continued refusal to have the blood sugar checked. During an interview on 1/9/2024 at 2:00 PM with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that nurses are supposed to notify a doctor and document if a resident refuses a blood sugar check in the progress notes. RNS 1 stated that if a resident with diabetes does not have his blood sugar levels checked he might become so hyperglycemic that the glucometer (machine that reads blood sugar levels) might be unable to read the resident's blood sugar level. RNS 1 stated that this may cause a diabetic resident to become very sick and be sent to the hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 6 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent interview and record review on 1/10/24 at 10:39 AM with RNS 2 at the nursing station, Resident 87's Medication Administration Record (MAR-a list of medications and treatments a resident is receiving) dated 12/1/2023-12/31/2023 was reviewed. The MAR indicated, Resident 87 refused blood sugar checks and a blood sugar result value was not documented. During an interview on 1/10/2024 at 3:19 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the doctor must be notified if a resident refuses blood sugar checks and it must be documented in the progress notes. LVN 2 stated physician must still be notified if a resident continuously refuses blood sugar checks. During a concurrent interview and record review on 1/10/24 at 3:37 PM with RNS 2, Resident 87's nursing progress notes from 12/1/2023 to 12/31/2023 were reviewed. The nursing progress notes did not have documentation for notifying a doctor after Resident 87 refused blood sugar checks. RNS 2 stated, the doctor needs to be notified if Resident 87 refuses blood sugar checks and it should be documented in the nursing progress notes if it was done. During a concurrent observation and interview on 1/11/2024 at 9:00 AM with Resident 87 in Resident 87's room, Resident 87 was observed becoming upset (started frowning and raised voice) when asked about his refusal of blood sugar checks. Resident 87 stated in an angry tone that he does not like getting his blood sugar checked because he does not like getting poked with needles and it bothers him. During a review of the facility's policy and procedure titled, "Change of Condition FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 7 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Reporting," dated 2/2023, indicated, "all changes in resident condition will be communicated to the physician" and "All attempts to reach the physician and responsible party will be documented in the nursing progress notes."

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 02/05/2024 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 8 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to take reasonable steps to protect three of eight sampled resident's (Resident 9, 59, 115) personal property from loss or theft in accordance with the facility's policy and procedure titled, "Personal Effects, Inventory of," for by failing to provide accurate and updated inventory of personal belongings. This deficient practice had the potential to result in the loss or theft of resident's belongings that has importance in their lives. Findings: 1. A review of Resident 9's Admission Record indicated the facility admitted Resident 9 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 9 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 7/25/2023 and then readmitted on 11/10/2023 with diagnoses that included dysphagia (difficulty swallowing), dementia (a group of thinking and social symptoms that interferes with daily functioning), and diabetes (a disease that result in too much sugar in the blood). A review of Resident 9's History and Physical dated 11/14/2023 indicated that Resident 9 did not have the capacity to make decisions. During an interview and concurrent record review of Resident 9's Inventory of Resident's Personal Belonging, dated 10/3/2023 and 7/25/2023, on 1/11/2024 at 9:40 AM, Social Services Designee (SSD) stated Resident 9's inventory list was done incorrectly. SSD stated, Resident 9's inventory list dated 10/3/2023, indicated that the resident did not have any belongings. SSD stated, Resident 9 was readmitted to the facility after a hospitalization and the certified nursing assistant (CNA) that completed the inventory form did not include Resident 9's personal items that were kept in storage for the resident while the resident was gone. SSD stated that the inventory list, dated 7/25/2023 indicated, Resident 9 had belongings that included 3 blouses, 2 jackets, 1 pair of shoes and 3 pants, that they were not carried forward to the new inventory list. SSD also stated that the inventory list from 10/30/2023 was not signed by staff or by Resident 9 which was indicated in the facility's policy to do. 2. A review of Resident 59's Admission Record indicated the facility admitted Resident 59 on 6/15/2022 with diagnoses that included morbid obesity (a serious health condition that results from an abnormally high body mass that is diagnosed by having a body mass index (BMI) greater than 40), hemiplegia (paralysis of one side of the body), and diabetes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 10 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 59's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/5/2023 indicated Resident 59 required set up or clean-up assistance with eating and personal hygiene. It also indicated that Resident 59 required substantial/maximal assistance with dressing, repositioning in bed and was completely dependent with toileting. A review of Resident 59's History and Physical dated 5/24/2023 indicated that Resident 25 had the capacity to make decisions. During an interview and concurrent record of Resident 59's Inventory of Resident's Personal Belongings dated 2/22/2023 at on 1/11/2024 at 9:35 AM, SSD stated that Resident 59's personal inventory list was done incorrectly. SSD stated the form was not signed by Resident 59 or a second staff member per facility policy. 3. A review of Resident 115's Admission Record indicated the facility admitted Resident 115 on 8/23/2022 and readmitted to the facility on 10/12/2023 with diagnoses that included dysphagia, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function), and diabetes. A review of Resident 115's MDS, dated 10/14/2023 indicated Resident 115 was dependent on staff for eating, bathing, hygiene, dressing, repositioning in bed. Resident 115's MDS also indicated that Resident 115 was severely cognitively impaired. A review of Resident 115's History and Physical dated 10/24/2023 indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 11 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 115 did not have the capacity to make decisions. During an interview and concurrent record of Resident 115's Inventory of Resident's Personal Belongings dated 10/23/2024 and 5/12/2023 at 1/11/2024 at 9:30 AM, SSD stated that the staff member who did Resident 115's inventory on 10/23/2024 did not do it correctly. The staff member put in the inventory list of Resident 115 that the resident had only one stuffed animal and one scarf. SSD stated that Resident 115 had more belongings kept in the storage when she went to the hospital. SSD stated that the inventory that was completed on 5/15/2023 (prior to hospitalization) indicated Resident 115 had belongings that included: four blouses, two sweaters, one pajama, one pair of shoes, three pair of pants, and the CNA who completed the personal inventory list upon Resident 115's return to the facility did not include those items. SSD also stated that both inventories did not have two signatures as indicated in the facility's policy. During an interview on 1/11/2024 at 9:23 AM, the SSD stated CNAs were primarily responsible for the completion of each resident's personal inventory list during admission or readmission to the facility. SSD stated that after the personal inventory list was completed, an RN supervisor was required to sign the inventory form, in addition to the CNA signature. SSD stated that the resident needs to sign the inventory form confirming the items were correct. In the case that the resident does not have capacity to understand or could not sign, the responsible party signs or informed, and it should be indicated on the form. SSD stated there should always be two signatures to verify and confirm to ensure the accuracy and integrity of the form and to protect the resident's belongings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 12 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/11/2024 at 12:10 PM. the Director of Nursing (DON) stated, when a resident comes back from a leave, the personal inventory form needs to be sure to include the items that were in storage for the resident when they were gone from the facility. DON stated that by not including those items, it could mean that the residents doesn't get their belongings back. DON further stated that there should be two staff signatures to verify the inventory and that the resident or resident's representative should sign as well. A review of the facility's policy titled, "Personal Effects, Inventory of," dated 5/2019, indicated that, "it is the facility's policy to take reasonable steps to protect the personal property of the residents." It also indicated that, "the inventory should include the recording of all personal clothing, valuables articles, etc., which are brought into the facility and retained by the resident," and that "following the completion of the inventory, the indicated form shall be signed by the resident and responsible party and by the staff member. If the resident is unable to sign, this shall be noted, including the reason for not able to sign should be indicated."

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 02/05/2024 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 13 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 46) was free from physical restraints (the use of a device that restrict freedom of movement of all or part of a person's body), by failing to ensure: 1. Resident 46 who had impaired cognition (ability to think and reason) was able to release the self-release belt (a belt that is placed around the residents waist while seated in the wheelchair which could restrict the resident's freedom to move or mobilize) without assistance. 2. A less a less restrictive measure was used to prevent Resident 46 from fall. 3. Identify the Self Release Belt as a restraint since Resident 46 could not release the selfFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 14 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE release belt without assistance. This deficient practice had the potential for Resident 46's rights being violated, not treated with respect and dignity and being held against her will. Findings: 1. A review of Resident 46's Face Sheet (an admission record) indicated the resident was readmitted to the facility on 7/26/2022 with diagnoses that included cerebral infraction (refers to damage to tissues in the brain due to a loss of oxygen), dementia (loss of cognitive functioning, thinking, remembering, and reasoning) A review of Resident 46's History and Physical Assessment dated 8/23/2022, indicated Resident 46 did not have the capacity to understand and make decisions. A review of Resident 46's Minimum Data Set (a resident assessment and care screening tool), dated 12/19/2023, indicated Resident 46 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on eating, oral hygiene, toileting, showers, upper and lower body dressing and personal hygiene. A review of Resident 46's Order Summary Report, indicated the facility may use selfrelease belt when up on wheelchair every shift, with a start date of 7/28/2022. The physician order did not specify the indication for the use of self-release belt. A review of Resident 46'sassessment form title " Restraint/Enabling Device/ Safety Device (define)", dated 12/19/2023, indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 15 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE current measures/devices may be used on side rails for positioning and ease in mobility as enabler (something that makes it possible for a particular thing to happen or be done), low bed with floor mat. May use self-release belt when up on wheelchair. During an observation on 1/9/2024 at 9AM, Resident 46 was observed in the hallway sitting on a wheelchair with a self-release belt tied with buckle in the front around Resident 46's waist that was attached to the wheelchair. Resident 46 was attempting to remove selfrelease belt but was not able to do so. During a concurrent interview Resident 46 was requested to remove the self-release belt but was unable to release the belt without assistance. During an observation and interview on 1/9/2024 at 11:09 AM with Medical Records Supervisor /Licensed Vocational Nurse (MRS/LVN) , Resident 46 was in hallway sitting in wheelchair with self-release belt wrapped around her waist and attached to the wheelchair. MRS/LVN asked Resident 46 if she was able to remove self-release belt. Resident 46's was observed grabbing the front buckle of the belt and attempting to remove the selfrelease belt but was not able to remove. MRS/LVN stated in the past Resident 46 was able to remove self-release belt without assistance, but now the resident is unable to release the belt on her own. MRS/LVN stated if Resident 46 was unable to remove self-release belt, Resident 46 should not have a selfrelease belt on as this is considered a physical restraint. During an interview with Director of Nursing on 1/09/2024 at 4:18 PM, the DON stated that residents should not be put on restraints. DON stated the use of self-release belt for Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 16 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 46 was to prevent the resident from fall because Resident 46 was high risk for falls due to the resident's history of falls. DON stated the self-release belt should not be used if the resident was unable to self-release the belt as it could be a danger to residents safety. A review of manufactures guidelines for "Resident Release Nylon-belt-quick release buckle", undated indicated "Caution: These belts are designed to be easily opened and removed by most residents. These belts are not considered to be restraints when used by residents who have the ability to open them at will or upon request. A review of facility policy Restraint dated 03,2023 indicated "it is the policy of this facility to only use physical restraints as last resort in the least restrictive manner when it is considered medically necessary through a systemic interdisciplinary process.

F644 SS=D Coordination of PASARR and Assessments CFR(s): 483.20(e)(1)(2)

F644 02/05/2024 §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 17 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to evaluate one of three sampled residents (Resident 125) using the Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals with mental illness or disability are not inappropriately placed in nursing homes for long term care) level I to identify suspected mental illness, intellectual/developmental disability, or related condition. Resident 125 had a diagnoses of mental illness such as schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), psychosis (when people lose some contact with reality), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities) and generalized anxiety disorder (can't control the worrying) and receiving psychotropic (drugs that affect a person's mental state) medication. This deficient practice resulted in delayed the PASRR Level II evaluation by the mental health department to ensure Resident 125 received the necessary mental health services that the resident needed to improve the quality of life. Findings: A review of Resident 125s face sheet (an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 18 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admission record) indicated the resident was admitted to the facility on 10/26/2023 with diagnoses of schizophrenia, Psychosis, major depressive disorder, and generalized anxiety disorder. A review of Resident 125s History and Physical Examination (H & P), dated 10/27/2023, indicated Resident 125 does not have the capacity to understand and make decisions. A review of Resident 125s Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 10/28/2023, indicated Resident 125 had severely impaired cognitive status (ability to think, remember, and reason). The MDS indicated Resident 125 was dependent (helper does all the effort) with all her Activities of Daily Living (ADL). A review of a PASRR completed by the General Acute Care Hospital (GACH) on 10/26/2023, indicated, Resident 125 had negative PASRR Level 1 screening (means the resident does not need to be evaluated for PASRR Level 2). The PASRR 1 screening indicated Resident 125 did not have a diagnoses that included schizophrenia, psychosis, major depressive disorder, generalized anxiety disorder and receiving psychotropic medications. However, Resident 125 was admitted to the facility on 10/26/24 from the GACH with diagnoses that included schizophrenia, psychosis, major depressive disorder, and generalized anxiety disorder. A review of PASRR completed by the facility, dated 1/9/2024, indicated, Resident 125 had positive PASRR Level 1 screening (means the facility will need to arrange for a Level 2 evaluation to be performed by the state approved contractor to help ensure the individual receives services in the most FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 19 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE integrated setting. The PASRR 1 screening also indicated for Resident 125 had the diagnoses of schizophrenia, psychosis, major depressive disorder, generalized anxiety disorder and receiving psychotropic medications (medications that affects mood and behavior). A review of Resident 125s Order Summary Report (OSR), dated 1/9/2024, indicated the resident received Escitalopram Oxalate (medication used to treat depression and anxiety) for depressive disorder, Risperidone (an antipsychotic medication that affects chemicals in the brain) 1 mg for schizophrenia, and Lorazepam (medication used to treat anxiety) as needed every six hours. A review of Resident 125s care plan, initiated 10/27/2023, indicated Resident 125 receives psychotropic medication use related to psychosis manifested by inappropriate laughter. A review of Resident 125s care plan, initiated 10/27/2023, indicated Resident 125 receives antidepressant medication use related to depression manifested by verbalization of sadness. A review of Resident 125s care plan, initiated 11/08/2023, indicated Resident 125 had psychotropic medication use related to schizophrenia manifested by mood swings. A review of Resident 125s care plan, initiated 11/15/2023, indicated Resident 125 had increased confusion and restlessness with agitation. A review of Resident 125s psychiatric evaluation dated 11/14/2023, indicated Resident 125 to continue medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 20 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE management for major depressive disorder and schizophrenia. A review of Resident 125s Medication Administration Record (MAR), dated 1/1/2024 until 1/11/2024, indicated Resident 125 received Lorazepam 0.5 mg seven times in 10 days. During a concurrent observation and interview on 1/08/2024 at 10:03 AM with Resident 125 in Resident 125s room, observed Resident 125 on her wheelchair facing the television mumbling unrecognizable words. When asked if she can be interviewed, Resident 125 stated "what do you want!", with irritated look. Observed Resident 125 verbalizing non sensical phrases. During a concurrent interview and record review on 1/9/2024 at 10:37 AM with Medical Record Supervisor Nurse (MRSN), Resident 125s physical chart and electronic medical record was reviewed. The MRSN stated, there was no documented evidence PASRR level 1 screening assessment was conducted for Resident 125. The MRSN stated, she was in charge of reviewing PASRR of the residents were admitted to the facility. The MRSN stated, PASRR screening should have been conducted when Resident 125 was admitted to the facility on 10/26/2023. During an interview on 1/9/2024 at 4:42 PM with the Director of Nurses (DON), DON stated, PASRR level 1 screening should have been done upon admission of the residents and should be evaluated for accurately. DON stated, since unable to locate the PASRR the facility will submit a PASRR today. During a concurrent interview and record review on 1/10/2024 at 1:15 PM with MRSN, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 21 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the MRSN indicated Resident 125s PASRR level 1 screening was completed on 1/9/2024 which indicated Resident 125's PASRR assessment was positive and a PASRR level II was required. MRSN stated, Resident 125's PASRR screening should have been done accurately so that Resident 125 would have received necessary mental health services needed. During an interview on 1/10/2024 at 2:15 PM with DON, DON stated, the PASRR screening done at GACH 1 was inaccurate, but the facility staffs who performed the PASRR screening did not confirm the accuracy of the assessment that Resident 1 had diagnoses of schizophrenia, psychosis, major depressive disorder, generalized anxiety disorder and receiving psychotropic medications. The DON stated, the facility should have evaluated the PASRR screening or have done another PASRR if the PASRR form could not be found upon admission. The DON stated, delay of PASRR II evaluation had the potential for Resident 125 to not receive the necessary mental health services she needed. A review of the facility's policy and procedure (P&P) titled, Pre-Admission Screening and Resident Review (PASRR), dated 12/2021, indicated: It is the policy of this facility to ensure that each resident is properly screened using PASRR specified by the State. The P&P procedures include; a) a PASRRR shall be completed on every resident upon admission, b) based upon assessment, the facility will ensure proper referral to appropriate state agencies for provisions of specialized services to residents with ID/RC (Intellectual Disability or Related Condition) or SMI (Serious Mental Illness), c) Social service shall contact the appropriate State Agency for referral of specialized care and services the resident may FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 22 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE require.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1)(3) 02/05/2024 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 23 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(iii) Be culturally-competent and traumainformed. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed develop a comprehensive, resident specific plan of care for two of two sampled residents (Resident 24 and Resident 46) who were placed on selfrelease/self-administer seat belt (a belt placed on a resident while seating on a wheelchair) due to resident making unassisted attempts of getting out of the wheelchair. This deficient practice had the potential to resulted in facility staff not monitoring the specific needs and care regarding the use of self-release belts for Resident 24 and Resident 46. Findings: 1. A review of Resident 24's Face Sheet (a document that gives a patient's information at a quick glance) indicated the resident was readmitted to the facility on 10/5/2017 with diagnoses that included dementia (loss of cognitive functioning - thinking, remembering, and reasoning), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) A review of Resident 24's History and Physical Assessment, dated 4/27/2023, indicated Resident 46 did not have the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 24 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 24's Order Summary Report (a physician's orders) for January 2024 indicated, the facility may apply self-administer belt, due to Resident 24 making unassisted attempts when getting out of the wheelchair, with a start date of 10/25/2022 A review of Resident 24's active care plan on 1/8/2024, indicated, the facility did not develop a resident specific comprehensive care plan for Resident 24 to address interventions on how Resident 24's could safely use, monitored or supervised while in use of self-release belt/selfadminister belt. 2. A review of Resident 46's Face Sheet indicated the resident was readmitted to the facility on 7/26/2022, with diagnoses that included cerebral infraction (refers to damage to tissues in the brain due to a loss of oxygen), dementia. A review of Resident 46's History and Physical Assessment, dated 8/23/2022, indicated Resident 46 did not have the capacity to understand and make decisions. A review of Resident 46's MDS, dated 12/19/2023, indicated Resident 46 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) on eating, oral hygiene, toileting, showers, upper and lower body dressing and personal hygiene. A review of Resident 46's Order Summary Report, indicated the facility may use selfrelease belt when up on wheelchair every shift, with a start date of 7/28/2022. A review of Resident 46's active care plans on 1/8/2024 indicated, the facility did not develop a resident specific comprehensive care plan to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 25 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE address interventions on how Resident 46's could safely use, monitored, or supervised while in use of self-release belt/self-administer belt. During an interview and concurrent record review of Resident 46's and Resident 24's Care plans on 1/8/2024 at 3:08 PM with Director of Nursing (DON), DON stated Resident 46 and Resident 24 did not have a care plan for the use of a self-release belt or self -administer belt care plans in their clinical records. A review of the facility's policy and procedure, titled "Comprehensive Person-Centered Care Planning with revision date of 1/2022 indicated "It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 02/05/2024 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 26 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to review, revised and update the care plan for one of eight sampled residents (Resident 25) who was discharged from hospice services (care services specialized for end-of-life care and needs) and continued to have a care plan regarding hospice care. These deficient practices placed Resident 25 at risk for not receiving necessary services and treatment which could impact quality of care and quality of life. Findings: A review of Resident 25's Admission Record indicated the facility admitted Resident 25 on 2/8/2023 with diagnoses that included dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), and diabetes (a group of diseases that result in too much sugar in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 27 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE blood. A review of Resident 25's MDS, dated 12/5/2023 indicated Resident 25 was independent in movement of the upper extremities (shoulder, elbow, wrist, hand) but required substantial/maximal assistance (helper does more than half the effort) for eating, hygiene, bathing, dressing, repositioning in bed. A review of Resident 25's History and Physical, dated 2/10/2023, indicated that Resident 25 had fluctuating capacity to make decisions. During an interview and concurrent record review of Resident 25's care plan on 1/11/2024 at 12:20 PM, the Director of Nursing (DON) stated, the care plan developed to address. Resident 25's nutritional care indicated the resident was still receiving hospice care with the intervention that included for the facility to contact the hospice care for needs. DON stated that Resident 25 was no longer on hospice services and that the care plan should have been updated. A review of the facility's policy titled, "Comprehensive Person-Centered Care Plan," dated 11/2016, indicated that the facility, "shall develop a comprehensive person-centered care plan for each resident," and that the "the resident's comprehensive plan of care will be reviewed and /or revised by the IDT (interdisciplinary team)."

F684 SS=D Quality of Care CFR(s): 483.25

F684 02/05/2024 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 28 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow care plan to ensure safe medication administration for one of five residents (Resident 70) with diagnosis of dysphagia (a medical term for swallowing difficulty). This failure resulted in Resident 70 not receiving resident centered care and had the potential for the resident to choke and aspirate (a condition in which food, liquid or medicine go down the wrong airway while swallowing) during medication administration. Findings: During a review of Resident 70's Admission Record, (a document containing demographic and diagnostic information), dated 1/11/2024, the admission record indicated that the resident was originally admitted to the facility on 4/18/2018 and readmission date of 4/10/2023, with diagnoses including dysphagia, acquired absence of other specified parts of digestive tract and aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction (stroke that happens where there is a loss of blood flow to part of the brain), and epilepsy (a brain disorder that causes recurrent seizures [uncontrolled burst of electrical activity in the brain]). During a review of Resident 70's Minimum Data Set (MDS-an assessment tool) dated 12/29/2023, indicated the resident had intact FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 29 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cognition (thought process and ability to reason or make decisions). It also indicated the resident required maximal assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident 70's "Swallowing problem and cognitive communication deficits" care plan, date initiated 12/18/2023, indicated under goals, "Patient will swallow pills 2 at a time to reduce bolus (a single dose of a drug or other preparation given all at once) hold and risks of aspiration (a condition in which food, liquid or medicine go down the wrong airway while swallowing)." During a review of Resident 70's Order Summary Report (a document containing a summary of all active physician orders), dated 1/11/2024, the report indicated following list of medications: 1. Aspirin (medication used to prevent heart attack [blockage of blood flow to heart] and stroke) tablet chewable, give 81 mg by mouth one time a day for CVA (cerebrovascular accident - stroke) prophylaxis (prevention). 2. Lactobacillus (medication used to keep the normal balance of bacteria in the gastrointestinal [tract or passageway of the digestive system] tract) tablet, give 2 tablets by mouth one time a day for supplement. 3. Levetiracetam (medication used to prevent seizures) oral tablet 1000 mg, give 1 tablet by mouth one time a day for seizure. DO NOT CRUSH. 4. Multi-Vitamin/Minerals (contain a combination of vitamins and minerals to increase nutrient intake) oral tablet, give 1 tablet by mouth one time a day for supplement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 30 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. Pyridoxine (Vitamin B6 supplement to prevent low Vitamin B6) HCl tablet 50 mg, give 50 mg (2 tablets of 25 mg) by mouth one time a day for supplement. 6. Sennosides (medication used to treat constipation) tablet 8.6 mg, give 2 tablets by mouth two times a day for bowel management, hold if with loose BM (BM - bowel movement). 7. Vitamin B (Vitamin B supplement to prevent low Vitamin B) complex oral tablet, give 1 tablet by mouth one time a day for supplement. During an observation on 1/10/2024 at 9:19 AM, Licensed Vocational Nurse (LVN) 3 provided seven different medications for a total of ten pills in one medicine cup to Resident 70. LVN 3 stated Resident 70 prefers to take all medications at one time. Resident 70 took all medications by mouth at once and was observed while he attempted to swallow the pills. LVN 3 encouraged Resident 70 to drink water and his nutritional supplement to assist with swallowing of medications. LVN 3 requested Resident 70 to open his mouth to show complete swallowing of pills. Resident 70 was observed opening mouth partially with some liquid coming out of the side of his mouth and puffed cheeks. Among the medications observed during administration, one of the seven medications, Aspirin was a chewable, and for one of the seven medications, Levetiracetam order indicated, "DO NOT CRUSH." During a concurrent observation and interview on 1/10/2024 at 9:46 AM with Resident 70 in resident's room, Resident 70 was not able to verbalize responses to questions. Resident 70 was observed to have difficulty swallowing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 31 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications for 27 minutes from the time when medication administration started. During an interview on 1/11/2024 at 10:20 AM with Speech Therapist (ST) 1, ST 1 stated Resident 70 has a history of low subglottal pressure, which means he needs a lot of breath support to make speech sounds. ST 1 stated Resident 70 was unable to say yes or no in short phrases during evaluation as opposed to what he was able to do previously. ST 1 stated Resident 70's condition has declined recently because he was not receiving therapy for a while. ST 1 stated in professional opinion it is best for everyone to take one tablet at a time to ensure smooth swallowing. During an interview on 1/11/2024 at 11:09 AM with Clinical Fellowship Year Speech Language Pathologist (CFY SLP), CFY SLP stated Resident 70 is aphonic (no voice or it comes and goes), doesn't have adequate breath support and that he cannot produce voice or cannot speak loudly. CFY SLP stated on 1/3/2024 during speech therapy, CFY SLP observed nurse giving one medicine cup with multiple medications to Resident 70 from which the resident took more than five pills at one time and held them in his mouth for some time. CFY SLP stated Resident 70 was coughing after holding medications for a long time. CFY SLP stated Resident 70 has a potential risk to aspirate if all the medications were taken together at one time. CFY SLP stated she educated the nurse that Resident 70 should be given one or two pills at a time to prevent aspiration. CFY SLP stated she spoke with LVN 7, but the education was not documented in resident's chart. CFY SLP stated that she expects nurses and doctors to review progress notes and to act on it. During an interview on 1/11/2024 at 11:36 AM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 32 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with LVN 3, LVN 3 stated there were five or six medications given to Resident 70 today which Resident 70 took together at once. LVN 3 stated Resident 70 took a couple of minutes to take medications, so LVN 3 waited in his room until resident swallowed the medications. LVN 3 stated there is a risk of choking if Resident 70 takes all medications together. LVN 3 stated medications can dissolve in mouth if parked for a while and can cause irritation in throat for Resident 70. LVN 3 stated no one has communicated with her about Resident 70's swallowing difficulty or how he should take medications. During an interview on 1/11/2024 at 11:51 AM with LVN 7 and CFY SLP, LVN 7 stated Resident 70 took all medications together at one time. LVN 7 stated she does not remember being told by CFY SLP about Resident 70's condition with swallowing difficulty. CFY SLP stated she remembers mentioning to LVN 7 during speech therapy. During an interview on 1/11/2024 at 4:11 PM with the Director of Nursing (DON), DON stated Resident 70 could cough or there could be aspiration if all the medications were given together at one time. DON stated, "there was a care plan dated 12/27/23 for swallowing of two pills at a time due to Laryngeal Response Duration (LRD)." During a review of Resident 70's Speech Therapy Treatment Encounter Note, dated 1/4/2024, the note indicated, "Pt observed taking multiple medicines at a time ....coughing and prolonged bolus hold was noted .....reported having difficulty demonstrating timely AP propulsion and swallow initiation ....clinician instructed patient to take two medicine and one sip of thin liquid at a time .....patient returned demo swallowing strategies FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 33 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in 60% of opportunities." During a review of Speech Language Pathologist Job Description document, dated 05/2023, the document indicated, "Speech Language Pathologist effectively communicates with supervisor and other health team members regarding patient progress, barriers, and treatment plans." During a review of the facility's policy and procedure (P&P) titled, "Six Rights of Medication Administration," dated 05/2018, the P&P indicated, "It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration. Right Medication Order - medications are checked against the order before they are given".

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 02/05/2024 SS=E CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 34 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review the facility failed to follow the faciltys' policy and procedure to prevent developement and worsening of pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction) by failing to: 1. Resident 90 was not weigh for 90 days to ensure the low air mattress settings (mattress designed to distribute resident's body weight over broad surface to prevent skin breakdown [damage to the skin that can result in redness, tenderness, or an open wound]) was at the correct settings. 2. Resident 78 was not turned and repositioned every two hours as ordered by physician and as indicated in the resident's care plan. Resident 78 was at risk for developing pressure injuries (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore). 3. For Resident 137, the facility failed to set the Alternating Pressure Mattress (mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation. Resident 137's body weighs 87 pounds (lbs.-a unit of measurement) and the resident's mattress was set for 200 lbs. resident. These deficient practices have the potential for the residents to develop worsened or new pressure ulcer or injury and/or delay the resident's wound healing. Findings: 1. During a review of Resident 90's "Admission Sheet," undated, it indicated Resident 90 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 35 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admitted to the facility in 6/2020 with diagnoses including but not limited to the following: insomnia (inability to sleep), anemia (low levels of red blood cells in the blood), and rectal abscess (collection of pus that develops near the rectum). During a review of Resident 90's "History and Physical (H&P)," dated 8/1/2023, it indicated Resident 90 has the capacity to understand and make decisions. During a review of Resident 90's "Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities and identifies health problems)," dated 12/22/2023, it indicated Resident 90 required maximal assistance with sitting to lying down, dressing lower the lower body (from the waist and below) and hygiene with toileting (ability to maintain personal hygiene). It indicated Resident 90 is incontinent (involuntary leakage) of urine and bowel (stool). The MDS also indicated Resident 90 uses a pressure reducing device for chair and bed, receiving surgical wound care, and nutrition or hydration interventions to manage skin problems. During a review of Resident 90's "Order Summary Report," it indicated Resident 90 had an active order from 12/7/2022 to have a low air loss mattress for skin management, settings according to resident's height and weight, and check function every shift. During a review of Resident's 90's electronic health record, it indicated Resident 90's was last weighed on 10/10/2022 at 138 pounds (lbs). During a review of Resident 90's Nursing Notes from 11/2022 to 1/2024, no nursing notes were documented indicating the resident refused FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 36 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weights to be taken. During a review of Resident 90's Interdisciplinary Team (IDT) Notes, dated 9/25/2023 and 12/22/2023, it stated to continue to discuss resident's plan of care, medications, and weight. During a concurrent observation and interview on 1/9/2024 at 2:30 PM with Treatment Nurse (TN) 1 in Resident 90's room, the settings on the low air mattress were observed to be at 140 lbs and 5 feet 11 inches. TN 1 stated the settings are incorrect as the resident is 138 lbs and 5 feet 6 inches. TN 1 stated having incorrect settings on the low air mattress can impede the function of the mattress and that the height and weight should be accurate. During an interview on 1/10/2024 at 12:54 PM with Registered Nurse (RN) 2, RN 2 stated staff are to encourage the resident if the resident refuses to be weighed, and it is brought up in IDT meetings. RN 2 further stated it is per facility policy to weigh all residents monthly but would need a Medical Doctor (MD) order if the resident needed to be weighed more frequently. RN 2 stated the risks of not being weighed monthly can compromise the resident's skin integrity if the setting is not correct on the low air mattress. During an interview on 1/11/2024 at 4:20 PM with the Director of Nursing (DON), DON stated there is no way to ensure settings on the low air mattress are accurate since there is no recent weight within the last 30 days for Resident 90. DON stated documentation for refusals should be charted in nurses' notes and should identify which interventions are not effective. DON further stated IDT meetings should be more specific to address which interventions are not effective and revise the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 37 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan as needed as IDT meeting notes did not list the resident's refusal for weights. During a review of the facility's policy and procedure (P&P) titled, "Nutrition and Hydration Program," revised on 5/2019, indicated residents will be weighed on admission and weekly for four, then monthly thereafter, unless otherwise ordered. It further stated Restorative Nurses will document weights in the resident's clinical record, and Licensed Nurses will document significant weight changes/hydration issues and additional assessment information and interventions in the Nurses Notes or Change of Condition. 2. During a review of Resident 78's "History and Physical (H&P)," dated 5/23/2023, the "H&P" indicated Resident 78 does not have the capacity to understand and make decisions, as well as active diagnosis of Huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), adult failure to thrive (a decline in adults that manifests as a downward spiral of health and ability), weight loss, and anxiety disorder. During a review of Resident 78's "Minimum Data Set (MDS)," dated 11/26/2023, the "MDS" indicated Resident 78 does not speak, has severely impaired vision, has urinary and bowel incontinence (lack of voluntary control over urination and defecation), a Stage I (wound that appears red, is painful, and has color and skin temperature changes) pressure injury, and required a repositioning program and pressure injury care. During a review of Resident 78's "Orders", dated 12/07/2021, the "Orders" indicated Resident 78 was to be turned and repositioned every two hours. During a review of Resident 78's "Care Plan", FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 38 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 12/11/2023, the "Care Plan" indicated, Resident 78 has the potential/actual impairment to skin integrity related to impaired mobility and interventions will reduce risk for impairment to skin integrity through the use of positioning techniques through review date (3/10/2024). "Care Plan" interventions and goals indicated turning and repositioning every two hours as tolerated. During an observation on 1/8/2024 at 8:15 AM in Resident 78's room, Resident 78 was observed laying on her back with bilateral arms and legs contracted (tightening of muscle, tendons, ligaments, or skin preventing normal movement of associated body parts). During a concurrent observation and interview on 1/8/2024 at 10 AM with CNA 1 in Resident 78's room, Resident 78 was observed laying on her back. CNA 1 stated Resident 78 was bedbound and required to be repositioned every two hours. During a concurrent observation and interview on 1/8/2024 at 12 PM with Resident 78's family member (FM 1), in Resident 78's room, Resident 78 was observed laying down on her back. FM 1 stated she was concerned Resident 78 was not getting repositioned because every time she visits, Resident 78 is always laying down on her back. During an observation on 1/8/2024 at 2 PM in Resident 78's room, Resident 78 was observed laying down on her back. During an interview on 1/9/2024 at 9:28 AM with the DSD, the DSD stated, the facility uses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 39 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a turning schedule to guide the CNAs how to reposition the residents at different times of the day. During an interview on 1/9/2024 at 9:43 AM with the DON, the DON stated residents who are dependent should be turned every two hours, and CNAs are required to document they repositioned the residents on electronic health record. DON stated CNAs are required to document at least every shift, for a total of three times. During a concurrent interview and record review on 1/11/2024 at 11:05 AM with the DON, Resident 78's "Turning/Reposition tasks" record, dated 12/17/2023, 12/18/2023, 12/24/2023, 12/26/2023, and 1/4/2024 was reviewed. The "Turning/Reposition tasks" record indicated, Resident 78 had only been turned one out of three shifts in a 24-hour period on those dates. DON stated this document is where CNAs are to document that they repositioned residents. DON stated, based on the electronic health record , Resident 78 had only been repositioned once in a 24- hour period on the above-mentioned dates. During a review of the facility's policy and procedure (P&P) titled, "Rounds, Turning", dated 5/2019, indicated, "Cleanse and reposition bedfast and wheelchair-bound residents on a regular basis". 3. A review of Resident 137's Face Sheet indicated Resident 137 was admitted to the facility on 8/25/2023, with diagnoses including malignant neoplasm of colon (cancer of the large intestine, which may affect the colon or rectum), persistent Atrial fibrillation (occurs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 40 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when the abnormal heart rhythm you experience lasts for more than a week). A review of Resident 137's History and Physical dated 12/15/2023 indicated Resident 137 has the capacity to understand and make decisions. A review of Resident 137's Minimum Data Set (MDS, a standardized resident assessment and care planning tool) dated 11/25/2023, indicated Resident 137's cognitive skills (the ways that your brain remembers, reasons, holds attention, solves problems, thinks, reads, and learns) were moderately cognitive impaired. The MDS indicated Resident 137 required extensive (resident involved in activity, staff provide guided maneuvering) one person assistance in bed mobility, dressing, toilet use, personal hygiene. The MDS dated 11/25/2023 section titled "Skin Conditions" indicated Resident 137's Skin and Ulcer/Injury treatments should include pressure reducing device for bed. A review of Resident 137's Order Summary Report, indicated the physician ordered on 12/15/2023, without an end date, indicated Resident 137 may have Low Air Loss mattress (LAL-a type of Alternating Pressure Mattress) for skin management with setting according to the resident's weight, and to check the function of the mattress every shift. A review of Resident 137's care plan, initiated on 12/15/2023, indicated Resident 137 had Sacro coccyx area deep tissue injury (skin injury characterized by purple or maroon discolored intact skin or blood?filled blister due prolonged unrelieved pressure or skin friction). The interventions included, the facility staff will administer treatments to the skin injury as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 41 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ordered by the physician and may have low air loss mattress for skin management with setting according to resident's body weight and will check function every shift. During an observation in Resident 137's room on 1/8/2024 at 8:26 AM, Resident 137 was observe lying in bed in supine position with the head of bed elevated and the LAL mattress setting was observed set at 200 pounds. During an observation in Resident's 137's room, and concurrent interview on 1/8/2024 at 9:32 AM with Treatment Nurse 1 (TN1), The TN stated Resident 137's low air loss mattress should always be in the correct setting according to the resident's weight to help Resident 137's wound to heal and prevent further pressure ulcer injury, TN 1 stated Resident 137's current weight was 84 lbs. TN 1 stated she did not know why the mattress was set at 200lbs. which was not the correct setting for the resident. During an observation and concurrent interview with TN 2 in Resident 137's room on 1/11/2024 at 9:26 AM, Resident 137 was observed lying in bed in supine position, head of bed elevated. Resident 137's LAL mattress was again observed at 200 lbs. setting.TN 2 stated Resident 137's LAL mattress should never be set at 200 lbs. because the mattress was hard and firm which could hurt Resident 137's wound rather than help to heal. A review of manufactures guidelines for MedAire 8" Alternating pressure mattress replacement system with Low Air Loss indicated "Product function-analog pressure dial adjust the dial to correspond to the patient's appropriate weight setting. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 42 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F688 Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/05/2024 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) for three out of seven sampled residents (Residents 125, 86, and 82) who was assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 125 received Restorative Nursing Aide (RNA) program (nursing aide program to help residents maintain their function and joint mobility) treatments for active assist range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 43 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE person) exercises to both upper extremities (BUE, shoulder, elbow, wrist, fingers) five (5) times a week as ordered by the physician. 2. Ensure Resident 86 received RNA treatments for donning (put on) of left elbow and left resting hand splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) 5 times a week as ordered by the physician. 3. Ensure Resident 82 received RNA treatments for BUE passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises and donning right elbow extension splint (splint to help straighten the elbow) 5 times a week as ordered by the physician. These deficient practices had the potential to cause further decline in Residents 125, 86, and 82's ROM and skin integrity. FINDINGS: 1. During an observation on 1/9/2024 at 11:18 AM, Resident 125 was sitting in the hallway, on a high back wheelchair that was reclined and tilted backwards including both leg rests. Resident 125 was able to answer simple questions, able to move both arms up and down a little below shoulder level and able to bend and straighten both elbows. Resident 125 was holding a remote control with the right hand. Resident 125 was able to move both ankles and bend both knees a little. A review of Resident 125's Admission Record indicated Resident 125 was admitted to the facility on 10/26/2023, with diagnoses including but not limited to, traumatic subdural hemorrhage (bleeding in the brain) without loss of consciousness, Type 2 diabetes mellitus (condition in which the body does not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 44 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE metabolize blood sugar correctly), and muscle weakness. A review of Resident 125's History and Physical chart note dated 10/27/2023, indicated Resident 125 did not have the capacity to understand and make decisions. A review of Resident 125's Minimum Data Set (MDS, a standardized assessment and carescreening tool) dated 10/28/2023, indicated Resident 125 had severe cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS also indicated Resident 125 required dependent assistance from staff for eating, oral hygiene, dressing, bathing, and chair to bed transfers. A review of Resident 125's Joint Mobility Evaluation dated 10/27/2023, indicated Resident 125 had no ROM limitations in BUE and both lower extremities (BLE, hip, knee, ankle, foot). A review of Resident 125's care plan dated 11/3/2023 indicated Resident 125 was at risk for decline in UE strength and ROM. The care plan goal was to maintain UE strength and ROM. The care plan intervention was for RNA for AAROM exercise to BUE 5 times a week, once a day as tolerated. A review of Resident 125's Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary dated 11/3/2023, indicated OT referred Resident 125 to RNA and a ROM program was established for RNA for UE AAROM, 5 times a week as tolerated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 45 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 125's Order Summary Report dated 1/9/2024 indicated a physician order dated 11/3/2023, for RNA for AAROM exercise to BUE, 5 times a week, once a day, as tolerated. A review of Resident 125's December 2023 Restorative Nursing flowsheet documentation for RNA for AAROM exercise to BUE 5 times a week, once a day as tolerated, indicated RNA initials on the following days during the week of 12/1/2023-12/7/2023: 12/2/2023, 12/4/2023, 12/6/2023, 12/7/2023 (There was 1 missed RNA treatment). The December 2023 Restorative Nursing flowsheet also indicated RNA initials on the following days during the week of 12/8/2023-12/14/2023: 12/9/2023, 12/11/2023, 12/13/2023, 12/14/2023 (There was 1 missed RNA treatment); The December 2023 Restorative Nursing flowsheet also indicated RNA initials on the following days during the week of 12/15/2023-12/21/2023: 12/16/2023, 12/18/2023, 12/20/2023 (There was 2 missed RNA treatments); The December 2023 Restorative Nursing flowsheet also indicated RNA initials on the following days during the week of 12/22/2023-12/28/2023: 12/23/2023, 12/26/2023, 12/28/23 (There was 2 missed RNA treatments). There was a total of 6 missed RNA treatments in December 2023. A review of Resident 125's January 2024 Restorative Nursing flowsheet documentation for RNA for AAROM exercise to BUE 5 times a week, once a day as tolerated indicated RNA initials on the following days during the week of 1/1/2024-1/7/2024: 1/1/2024, 1/4/2024, 1/6/2024. There was a total of 2 missed RNA treatments in January 2024. During an interview and concurrent record review of Resident 125's RNA treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 46 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE flowsheet documentation, on 1/9/2024 at 11:55 AM, the Director of Staff Development (DSD) stated RNAs should follow the physician's orders and provide RNA treatments for the frequency ordered, because the purpose of RNA was to maintain a resident's mobility after rehabilitation therapy. The DSD stated if there was an "X" on the sheet, then it meant the resident was not seen for RNA treatment that day. If there were initials, then it meant the RNA saw the resident that day. The DSD stated Resident 125 had an order for RNA for 5 times a week for AAROM exercises to BUE and the DSD stated Resident 125 was not seen 5 times a week for RNA for AAROM exercises to BUE. The DSD stated Resident 125 was only seen 3 times a week. The DSD stated there was no documentation that Resident 125 refused or did not tolerate RNA more than 3 times a week. The DSD stated that if RNAs did not perform the RNA treatments as ordered by the physician, the residents had a risk for decline in ROM and could develop contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During an interview on 1/10/2024 at 10:06 AM, the Occupational Therapist (OTR 1) stated it was important for residents to have as much of their joint ROM as possible, because residents would have less movement in their joints, which can put them at risk for decreased skin integrity. 2. During an observation and interview on 1/9/2024 at 8:49 AM in Resident 86's room, Resident 86 was laying on his back in bed with the head of bed up more than halfway. Resident 86 was able to move the right upper extremity without any limitations. Resident 86 stated he was not able to move his left arm or leg. Resident 86's left elbow was bent less than FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 47 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE halfway; the left wrist was bent forward and the left fingers were straight and was not wearing any splints. Resident 86 stated he received RNA treatment about two to three times a week. A review of Resident 86's Admission Record indicated the resident was admitted to the facility on 7/30/2022 with diagnoses including, but not limited to, hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side, and muscle weakness. A review of Resident 86's History and Physical Examination dated 10/25/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 86's MDS dated 10/22/2023, indicated Resident 86 was independent with eating and oral hygiene, required moderate assistance with upper body dressing, chair transfer and toilet transfer, and dependent assistance from staff with lower body dressing. A review of Resident 86's Joint Mobility quarterly Evaluation dated 10/20/23 indicated Resident 86 did not have any ROM limitations in the right hip, knee, ankle, wrist, fingers, shoulder flexion (moving arm forward up and down), shoulder abduction (moving arm sideways up and down), and left hip. The joint mobility quarterly evaluation also indicated Resident 86 had minimal ROM limitations in the left knee, ankle, elbow and moderate ROM limitations in the left wrist, fingers, shoulder flexion, and shoulder abduction. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 48 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 86's care plan revised 11/13/2023, indicated Resident 86 "requires RNA program related to potential for decline in functional status and ROM. The care plan goal indicated the resident "to tolerate left elbow and left resting hand splint for 4 to 6 hours to decrease pain and prevent left UE contracture without skin irritation." The care plan intervention indicated for "RNA to provide donning of left elbow and left resting hand splint to decrease pain and prevent left contracture with skin checks and orthotic hygiene for 4 to 6 hours as tolerated once a day 5 times a week." A review of Resident 86's Occupational Therapy Recertification, Progress Report and Updated Therapy Plan dated 11/13/2023 indicated "OT to also increase frequency of RNA to provide donning of left elbow and left resting hand splint ...5 times a week." A review of Resident 86's Order Summary Report dated 1/9/2024 indicated a physician order dated 11/13/2023, for RNA to provide donning of left elbow and left resting hand splint to decrease pain and prevent left contracture with skin checks and orthotic (an external device to support, align, or correct a movable part of the body) hygiene for four (4) to six (6) hours as tolerated once a day 5 times a week. A review of Resident 86's December 2023 Restorative Nursing flowsheet documentation for RNA treatment for donning of left elbow and left resting hand splint to decrease pain and prevent left contracture with skin checks and orthotic hygiene for 4 to 6 hours as tolerated once a day 5 times a week indicated RNA initials on the following days during the week of 12/1/2023-12/8/2023: 12/2/2023, 12/4/2023, 12/7/2023 (There was 2 missed RNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 49 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatments); The December 2023 Restorative Nursing flowsheet also indicated RNA initials on the following days during the week of 12/8/2023-12/14/2023: 12/9/2023, 12/11/2023, 12/14/2023 (There was 2 missed RNA treatments); The December 2023 Restorative Nursing flowsheet also indicated RNA initials on the following days during the week of 12/15/2023-12/21/2023: 12/16/2023, 12/18/2023, 12/20/2023 (There was 2 missed RNA treatments); The December 2023 Restorative Nursing flowsheet also indicated RNA initials on the following days during the week of 12/22/2023-12/28/2023: 12/23/2023, 12/25/2023, 12/27/2023 (There was 2 missed RNA treatments). There was a total of 8 missed RNA treatments during December 2023. A review of Resident 86's January 2024 Restorative Nursing flowsheet documentation for RNA treatment for donning of left elbow and left resting hand splint to decrease pain and prevent left contracture with skin checks and orthotic hygiene for 4 to 6 hours as tolerated once a day 5 times a week indicated RNA initials on the following days during the week of 1/1/2024-1/7/2024: 1/1/2024, 1/3/2024, 1/5/2024, 1/6/2024. There was a total of 1 missed RNA treatment in January 2024. During an interview and concurrent record review of Resident 86's RNA treatment flowsheet documentation, on 1/9/2024 at 11:21 AM, Restorative Nursing Aide (RNA 2) reviewed Resident 86's December 2023 RNA treatment flowsheet and stated that if there was an initial on the date, that meant the RNA treatment was completed. RNA 2 stated that if there was an "X" on the date, that meant the RNA treatment was not completed that day. RNA 2 reviewed the December 2023 RNA treatment flowsheet and confirmed Resident 86 was seen three times a week for RNA, instead FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 50 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of 5 times a week as ordered by the physician. RNA 2 stated the RNAs were supposed to follow the orders for RNA provided by the therapists. During an interview and concurrent record review of Resident 86's RNA treatment flowsheet documentation, on 1/9/2024 at 11:55 AM, the DSD stated RNAs should follow the physician's orders and provide RNA treatments for the frequency ordered. The DSD stated the purpose of RNA was to maintain a resident's mobility after rehabilitation therapy. The DSD reviewed Resident 86's January 2024 RNA treatment flowsheet and stated Resident 86 was not seen 5 times a week for donning of left elbow and left resting hand splint and there was no evidence of any documentation that the resident refused or was attempted to be seen 5 times week for RNA treatment. The DSD stated that if RNAs did not see residents as ordered, the residents could decline in their ROM, walking, or mobility, or be more contracted in the joints if the splints are not put on. During an interview on 1/10/2024 at 10:06 AM, OTR 1 stated OTR 1 recommended RNA for Resident 86 for LUE splinting to maintain Resident 86's current ROM and prevent contractures from forming and getting worse. OTR 1 stated for example, Resident 86's left hand could get tight and not open up anymore. OTR 1 stated if the splints were not put on for the 5 times a week as ordered, then Resident 86 was at risk for the ROM to continue to get worse which could compromise skin integrity and Resident 86 would have less movement. OTR 1 stated it was important for a resident to have as much range of motion in their joints as possible. 3. During an observation on 1/9/2024 at 8:40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 51 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AM, Resident 82 was laying in bed on the back in a slanted position. Resident 82 did not speak or respond to questions or instructions. Resident 82's right hand was in a fist and Resident 82 was able to lift the right arm up and touch the right fist to the face and chest. Resident 82's left elbow was bent, wrist bent forward, and the left hand was relaxed. No splints were observed on Resident 82's upper extremities. A review of Resident 82's Admission Record indicated Resident 82 was initially admitted to the facility on 5/28/2021 and readmitted to the facility on 1/9/2023 with diagnoses including, but not limited to, hepatic encephalopathy (any damage or disease that affects the brain), Type Two diabetes mellitus without complications, and dementia (group of thinking and social symptoms that interferes with daily functioning). A review of Resident 82's MDS dated 10/7/2023 indicated Resident 82 had severe cognitive impairments. The MDS also indicated Resident 82 required dependent assistance from staff for eating, bathing and shower transfers. The MDS also indicated Resident 82 required substantial assistance from staff to complete oral hygiene, dressing, bed to chair transfers, and sit to lying. A review of Resident 82's History and Physical Examination dated 1/12/2023 indicated Resident 82 did not have the capacity to understand and make decisions. A review of Resident 82's care plan dated 11/7/2023 indicated Resident 82 had a potential risk for decline in BUE ROM. The care plan goal was to maintain current ROM through target date. The care plan intervention indicated for RNA to provide BUE PROM once a day, 5 times a week or as tolerated and RNA to apply right elbow extension splint for up to 3.5 hours once a day, 5 times a week or as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 52 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tolerated. A review of Resident 82's physician's Order Summary Report dated 1/19/2024 indicated an order dated 11/7/2023 for RNA to apply right elbow extension splint for up to three and a half (3.5) hours once a day, 5 times a week or as tolerated. The physician's Order Summary Report also indicated an order dated 11/7/2023 for RNA to provide BUE PROM once a day, 5 times a week or as tolerated. A review of Resident 82's joint mobility evaluation dated 1/4/2024 indicated Resident 82 did not have ROM limitations in BUE and BLE. A review of Resident 82's Occupational Therapy Recertification, Progress Report, and Updated Therapy Plan dated 11/7/2023 indicated OT established a range of motion program and trained RNA to provide BUE PROM once a day, 5 times a week or as tolerated and established a splint and brace program and trained RNA to apply right elbow extension splint for up to 3.5 hours once a day, 5 times a week or as tolerated. A review of Resident 82's November 2023 RNA flowsheet documentation for RNA treatment for RNA to apply right elbow extension splint for up to 3.5 hours once a day, 5 times a week or as tolerated indicated the RNA's initial on the following days during the week of 11/8/202311/14/2023: 11/9/2023, 11/11/2023, 11/14/2023 (There were 2 missed RNA treatments); The November 2023 RNA flowsheet also indicated the RNA's initials on the following days during the week of 11/15/2023-11/21/2023: 11/15/2023, 11/18/2023, 11/20/2023 (There were 2 missed RNA treatments); The November 2023 RNA flowsheet also indicated the RNA's initials on the following days during the week of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 53 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/22/2023-11/28/2023: 11/23/2023, 11/25/2023, 11/27/2023 (There were 2 missed RNA treatments) There was a total 6 missed RNA treatments during November 2023 . A review of Resident 82's November 2023 RNA flowsheet documentation for RNA treatment for RNA to provide BUE PROM once a day, 5 times a week or as tolerated indicated the RNA's initial on the following days during the week of 11/8/2023-11/14/2023: 11/9/2023, 11/11/2023, 11/14/2023 (There were 2 missed RNA treatments); The November 2023 RNA flowsheet also indicated the RNA's initials on the following days during the week of 11/15/2023-11/21/2023: 11/15/2023, 11/18/2023, 11/20/2023 (There were 2 missed RNA treatments); The November 2023 RNA flowsheet also indicated the RNA's initials on the following days during the week of 11/22/2023-11/28/2023: 11/23/2023, 11/25/2023, 11/27/2023 (There were 2 missed RNA treatments) There was a total 6 missed RNA treatments during November 2023. A review of Resident 82's December 2023 RNA flowsheet documentation for RNA treatment for RNA to apply right elbow extension splint for up to 3.5 hours once a day, 5 days a week or as tolerated indicated RNA initials on the following days during the week of 12/1/2023-12/7/2023: 12/2/2023, 12/4/2023, 12/7/2023 (There were 2 missed RNA treatments). The December 2023 RNA flowsheet also indicated RNA initials on the following days during the week of 12/8/2023-12/14/2023: 12/9/2023, 12/11/2023, 12/14/2023 (There were 2 missed RNA treatments). The December 2023 RNA flowsheet also indicated RNA initials on the following days during the week of 12/15/202312/21/2023: 12/16/2023, 12/18/2023, 12/20/2023, 12/21/2023 (There was 1 missed RNA treatment). The December 2023 RNA flowsheet also indicated RNA initials on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 54 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE following days during the week of 12/22/202312/28/2023: 12/23/2023, 12/26/2023, 12/28/2023 (There were 2 missed RNA treatments). There was a total of 7 missed RNA treatments during December 2023. A review of Resident 82's December 2023 RNA flowsheet documentation for RNA treatment for RNA to provide BUE PROM once a day, 5 days a week or as tolerated indicated RNA initials on the following days during the week of 12/1/2023-12/7/2023: 12/2/2023, 12/4/2023, 12/6/2023 (There were 2 missed RNA treatments). The December 2023 RNA flowsheet also indicated RNA initials on the following days during the week of 12/8/202312/14/2023: 12/9/2023, 12/11/2023, 12/13/2023 (There were 2 missed RNA treatments). The December 2023 RNA flowsheet also indicated RNA initials on the following days during the week of 12/15/202312/21/2023: 12/16/2023, 12/18/2023, 12/20/2023 (There were 2 missed RNA treatment). The December 2023 RNA flowsheet also indicated RNA initials on the following days during the week of 12/22/202312/28/2023: 12/23/2023, 12/25/2023, 12/27/2023 (There were 2 missed RNA treatments). There was a total of 8 missed RNA treatments during December 2023. A review of Resident 82's January 2024 RNA flowsheet documentation for RNA treatment for RNA to apply right elbow extension splint for up to 3.5 hours once a day, 5 times a week or as tolerated indicated the RNA's initials on the following days during the week of 1/1/20241/7/2024: 1/1/2024, 1/4/2024, 1/6/2024: There was a total of 2 missed RNA treatments during January 2024. A review of Resident 82's January 2024 RNA flowsheet documentation for RNA treatment for RNA to provide BUE PROM once a day, 5 times a week or as tolerated indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 55 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE RNA's initials on the following days during the week of 1/1/2024-1/7/2024: 1/1/2024, 1/4/2024, 1/6/2024: There was a total of 2 missed RNA treatments during January 2024. During an interview and concurrent record review of Resident 82's January 2024 RNA treatment flowsheet documentation, on 1/9/2024 at 11:55 AM, the DSD stated RNAs should follow the physician's orders and provide RNA treatments for the frequency ordered. The DSD stated the purpose of RNA was to maintain a resident's mobility after rehabilitation therapy. The DSD stated if there was an "X" on the treatment flowsheet documentation, then it meant the resident was not seen that day. The DSD confirmed Resident 82 had RNA orders to provide BUE PROM 5 times a week and for RNA to apply right elbow extension splint for 3.5 hours 5 times a week. After review of Resident 82's January 2024 RNA treatment flowsheet documentation, the DSD stated Resident 82 was not seen for RNA 5 times a week for RNA to provide BUE PROM or for RNA to apply right elbow extension splint for 3.5 hours. The DSD confirmed there was no documentation that resident refused or could not tolerate RNA for 5 times a week. The DSD stated that Resident 82 could be more contracted and decline in ROM if RNA did not perform RNA treatment 5 times a week as ordered. During an interview on 1/10/2024 at 10:06 AM, OTR 1 stated the purpose of splinting was to help reduce the risk for contractures or contractures from getting worse. OTR 1 stated that putting on splints 5 times a week was the standard frequency to prevent residents from forming contractures and ROM to get worse. OTR 1 stated it was important for residents to have as much of their joint range of motion as possible, because residents would have less FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 56 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE movement in their joints which can put them at risk for decreased skin integrity. A review of the facility's policies and procedures, revised 11/2019, titled, "Restorative Program Overview," indicated to "provide direct nursing care services that will maintain optimum physical and mental health for the resident and meet his medical treatment needs."

F695 SS=E Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 02/05/2024 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to promote resident safety in administering oxygen for two (2) of 2 sampled residents (Resident 262 and 261) who were receiving continuous oxygen therapy, in accordance with the facility's policy and procedure by failing to: 1. Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor for Resident 262. 2. Ensure the humidifier bottle (a water bottle that aids in preventing patients' airways from becoming dry) was labeled with open date for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 57 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 262. 3. Ensure the oxygen tubing was labeled with an open date for Resident 262 and 261. This deficient practice had the potential for Resident 262 and 261 to contract infection when receiving oxygen therapy which could increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: 1. A review of Resident 262's Face Sheet (a document that gives a patient's information at a quick glance) indicated an admission to the facility on 1/4/2024 with diagnoses that included end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant [surgery to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function] to maintain life), type 2 diabetes mellitus (long-term medical condition in which your body doesn't use insulin (hormone that helps body turn food into energy and controls blood sugar levels) properly, resulting in unusual blood sugar levels) with diabetic neuropathy (nerve damage that can occur with diabetes), and dependence on renal dialysis. A review of Resident 262's undated History and Physical Assessment, indicated Resident 262 had the capacity to understand and make decisions. A review of Resident 262's Order Summary Report dated 1/4/2024, indicated a physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 58 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order for Oxygen therapy at 2 liters (L, unit of measure) per minute continuous every shift. During an observation in Resident 262's room on 1/8/2024 at 10:33 AM, Resident 262 was observed receiving oxygen therapy via nasal cannula (medical device to provide supplemental oxygen therapy). Resident 262's oxygen tubing was touching the floor and the oxygen tubing and humidifier bottle was observed not labeled with open date. During a concurrent observation and interview with licensed vocational nurse (LVN) 1 on 1/8/2024 at 10:37 AM, LVN 1 confirmed Resident 262's oxygen tubing was touching the floor and the oxygen tubing and humidifier bottle was not labeled with open date. LVN 1 stated it was not okay for oxygen tubing to touch the floor because of cross contamination and infection control. LVN 1 stated she would change and label the oxygen tubing and humidifier bottle for Resident 262. 2. A review of Resident 261's Face Sheet indicated an admission to the facility on 1/2/2024 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affection right non-dominant side, hyperlipidemia (high cholesterol [too many lipids [fats] in blood]), and chronic obstructive pulmonary disease (COPD, chronic inflammatory disease that causes obstructed airflow from the lungs) with (acute) exacerbation (flare up). A review of Resident 261's History and Physical Assessment, indicated Resident 261 had fluctuating capacity to understand and make decisions. A review of Resident 261's Order Summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 59 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Report dated 1/4/2024, indicated a physician order for Oxygen therapy at 4L per minute continuous every shift. During an observation in Resident 261's room on 1/8/2024 at 10:52 AM, Resident 261 was observed receiving oxygen therapy via nasal cannula. Resident 261's oxygen tubing was not labeled with open date. During a concurrent observation and interview with the treatment nurse (TN) on 1/8/2024 at 11:07 AM, TN confirmed Resident 261's oxygen tubing was not labeled with open date. TN stated it is important for tubing to be labeled to make sure it is for the right patient and to know when to change the tubing. TN stated she will change and label Resident 261's oxygen tubing. A review of the facility's policy and procedure titled "Oxygen, use of" dated 5/2021 indicated the facility will promote resident safety in administering oxygen. The policy indicated tubing, masks, humidifiers, and other disposables used for Oxygen administration will be dated. The policy indicated the tubing should be kept off the floor.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 02/05/2024 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 60 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review the facility failed to do a pain reassessment after one hour of administering Norco (prescribed medication to treat moderate to severe pain) and Tylenol (medication to treat mild to moderate pain) for one of one sampled resident (Resident 56). This failure had the potential to result in not identifying the effectiveness of pain medications. Findings: During a review of Resident 56's "Admission Sheet," undated, it indicated Resident 56 was admitted to the facility in 9/2023 with diagnoses including but not limited to the following: chronic obstructive pulmonary disease (COPD, condition that does not allow the lungs to fully expand and exchange oxygen and carbon dioxide) with acute exacerbation (sudden worsening of symptoms), purapura (purplecolored spots that occur on the skin), and atherosclerotic heart disease (a buildup of cholesterol in artery walls). During a review of Resident 56's "History and Physical (H&P)," dated 9/5/2023, it indicated Resident 56 has the ability to make medical decisions. During a review of Resident 56's "Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities and identifies health problems)," dated 12/8/2023, indicated Resident 56 was dependent in transfers to and off a toilet. During a review of Resident 56's "Order Summary Report," it indicated Resident 56 had an active order dated 9/4/2023 for Norco 5-325 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 61 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE milligrams (mg) every six hours as needed for moderate to severe pain, and Tylenol 325 mg every four hours as needed for mild pain. During a review of Resident 56's "Medication Administration Record (MAR)," it indicated Resident 56 was given pain medication on the following days: On 12/18/2023, Tylenol was given at 9:51 AM and reassessed for effectiveness four hours later at 1:54 PM. On 12/18/2023, Norco was given at 9:51 AM and reassessed for effectiveness five hours later at 11:25 PM. On 12/22/2023, Tylenol was given at 9:18 AM and reassessed for effectiveness four hours later at 1:09 PM. On 12/28/2023, no pain reassessment was completed for Tylenol. On 12/31/2023, Norco was given at 1:27 AM and reassessed four hours later for effectiveness at 5:57 AM. On 1/6/2024, Tylenol was given at 8:43 AM and reassessed for effectiveness six hours later at 2:40 PM. On 1/10/2024, Tylenol was given at 12:35 PM and no pain reassessment was completed. During a concurrent interview and record review on 1/10/2024 at 3:07 PM with Licensed Vocational Nurse (LVN) 4, Resident 56's "MAR," dated December 2023 to January 2024, was reviewed. The MAR indicated the pain reassessment of Tylenol was not completed on 12/28/2023 and 1/10/2024. LVN 4 stated, pain reassessments should be done FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 62 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE after one hour for all pain medications and should be documented in the MAR. LVN 4 stated the pain reassessment was not completed for Tylenol which was given at 12:46 PM. LVN 4 stated the pain reassessment should've been completed and charted in Resident 56's MAR no later than 2:00 PM to indicate if the pain medication is effective. During a review of the facility's policy and procedure (P&P) titled, "Pain Management," revised 5/2019, indicated medication(s) received, refused and response to medication will be documented on the MAR. It further indicated to monitor pain status and treatment effects on a regular basis.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/05/2024 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 63 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of four of six sample residents (Resident 65,26,310,90) by failing to: 1. Clarify physician orders with overlapping pain scale for Resident 65, which created a potential for duplication of opioid (a class of drugs associated with high potential for abuse) therapy. This failure had the potential to result in opioid overdose and increased risk for adverse consequences such as respiratory depression (trouble breathing) for Resident 65. 2. Accurately account for the use of controlled substances (medications with a high potential for abuse) for Residents 26 and 310) in medication carts (Medication Cart 1A and Medication Cart 2C). These failures had the potential to result in unintended use of discontinued order of Zolpidem (a controlled substance used to treat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 64 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sleep problems) for Resident 26, and Methadone (a controlled substance used to relieve chronic pain and to manage and treat opioid use disorder) for Resident 310. These failures placed the facility and Resident 26 and Resident 310 at risk for medication errors, misuse, drug loss, diversion, and accidental exposure to controlled substances to residents and staff. 3. Ensure Xanax (a medication to treat anxiety) was documented on the Controlled Substance Count Sheet (form that is filled out each time a controlled substance [medications that are tightly controlled because of the abuse potential] is taken out of the medication cart and to give to the resident) and Medication Administration Record (MAR) as given to a resident for resident (Resident 90). This failure had the potential for potential risk for double dosing the resident and drug diversion (illegal distribution or abuse of prescription drugs for their unintended purposes). Findings: 1. During a review of Resident 65's Admission Record, (a document containing demographic and diagnostic information), dated 1/11/2024, the admission record indicated that the resident was admitted to the facility originally on 9/16/2023 with diagnoses including arthritis, multiple sites, and difficulty in walking. During a review of Resident 65's Minimum Data Set (MDS-an assessment tool) dated 12/18/2023, the MDS indicated the resident had moderate cognitive (thought process and ability to reason or make decisions) impairment. Resident 65's MDS indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 65 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident required maximal assistance from staff with personal hygiene, dressing, showering and toileting hygiene. During a review of Resident 65's Order Summary Report (a document containing a summary of all active physician orders), dated 11/30/2023 and 1/11/2024, the orders indicated: a. An order for a combination medication that contained 5 milligrams (mg) of "oxycodone (a controlled substance used to relieve moderate to severe pain) and 325 mg of acetaminophen ([APAP]) a non-controlled pain reliever), give 1 tablet by mouth every 4 hours as needed for moderate pain (4-10). Not to exceed (NTE) 3 grams (gm) in 24 hours from all APAP sources", order date 9/19/2023; and b. An order for "Percocet (Generic nameoxycodone/APAP) 10/325 mg, give 1 tablet by mouth every 4 hours as needed for severe pain (7-10). NTE 3 gm in 24 hours from all APAP sources", order date 9/18/2023. During a review of Resident 65's Care Plan, creation date 9/16/2023, the care plan indicated focus of risk for adverse reaction related to polypharmacy (situation where resident is on five or more medications). During a review of Resident 65's Medication Administration Record (MAR, a written record of all medications given to a resident), the MAR indicated physician orders as follows: Order for Oxycodone/APAP 10/325 mg indicated as needed for severe pain (Pain level 7-10). Resident 65 received Oxycodone/APAP 10-325 for pain level 6, outside the physician order parameters on following dates and times: 12/5/2023 at 12:27 PM 12/6/2023 at 7:57 AM, 12:15 PM and 5:06 PM 12/7/2023 at 4:02 PM, 8:15 PM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 66 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/8/2023 at 8:39 AM and 4:00 PM 12/9/2023 at 1:31 PM 12/10/2023 at 9:24 AM, 12/11/2023 at 8:32 PM 12/12/2023 at 8:30 AM 12/13/2023 at 8:15 AM and 12:20 PM 12/18/2023 at 9:14 AM 1/1/2024 at 7:55 AM and 12:31 PM 1/3/2024 at 1:25 PM 1/8/2024 at 12:13 PM Order for Oxycodone/APAP 5/325 mg indicated as needed for moderate pain (Pain level 4-10). Resident 65 received Oxycodone/APAP 5-325 for pain level greater than or equal to 7, which was an overlapping pain level parameter with the order for Oxycodone/APAP 10/325 mg for severe pain (Pain level 7-10) on following dates and times: 12/1/2023 at 5:20 PM 12/2/2023 at 9:24 AM and 5:34 PM 12/3/2023 at 9:39 AM and 4:52 PM 12/4/2023 at 4:31 PM 12/14/2023 at 4:22 PM 12/15/2023 at 7:39 AM, 1:49 PM and 8:03 PM 12/16/2023 at 9:36 AM and 2:40 PM 12/17/2023 at 10:01 AM 12/20/2023 at 3:31 PM 12/22/2023 at 5:00 AM 12/25/2023 at 5:11 AM, 10:06 AM and 9:30 PM 12/26/2023 at 5:57 AM 12/28/2023 at 6:18 AM 12/29/2023 at 12:06 AM, 8:38 AM and 12:40 PM 12/31/2023 at 3:20 PM and 7:34 PM 1/2/2024 at 11:52 PM 1/4/2024 at 1:05 PM During an interview on 1/11/2024 at 2:10 PM with Resident 65, Resident 65 stated, he has pain in his kneecaps, that usually hurt when he takes a wrong step. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 67 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/11/2024 at 2:30 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, "Percocet 10/325 mg is for severe pain 7-10 and oxycodone/APAP 5/325 mg for moderate pain 4-10. If pain level is at 8, he will ask for 10/325mg". LVN 2 stated, she will clarify orders with physician because it should state moderate pain 4-6. LVN 2 stated there is a risk that due to unclear pain scale, resident can go untreated for pain if given less pain medication and stated there is a risk that resident can get overdosed if given more than necessary medication. During a review of the facility's policy and procedure (P&P) titled, "Pain Management", dated 5/2019, the P&P indicated, "Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome .... The Interdisciplinary Care Plan will reflect the location and type of pian, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated." 2a. During a review of Resident 26's Admission Record, dated 1/11/2024, the admission record indicated, the resident was admitted to the facility initially on 12/3/2020 with diagnoses including dementia with unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder. During a review of Resident 26's Order Summary Report (a document containing a summary of all active physician orders), dated 11/30/2023 and 1/11/2024, the order summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 68 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reports did not indicate any physician orders for Ambien (Generic name - Zolpidem) 5 mg. During a review of Resident 26's Physician Active Orders on EHR, dated 1/10/2024, the orders indicated an order date of 3/7/2022 at 13:54 (1:54 PM) confirmed by LVN 11 for Ambien Tablet 5 mg (Zolpidem Tartrate) Give 1 tablet by mouth every 24 hours as needed for sleep aid. A further review indicated prescriber note to discontinue this order on 3/23/2022 at 14:39 (2:39 PM) stating "14 days are up". During a review of Resident 26's available care plans, last revised on 3/30/2022, indicated "resolved intervention for at risk for inability to sleep related to insomnia (Ambien)". During a concurrent interview and record review on 1/10/2024 at 12:15 PM with LVN 8, medication card for Zolpidem 5 mg was available in the medication cart with quantity of 24 tablets remaining, and Controlled Drug Record indicated, Zolpidem 5 mg was charted six times during the months of 06/2023 and 07/2023. The charting dates and times on CDR were documented as follows: 6/27/2023 4:32 AM 6/29/2023 16:30 (4:30 PM) 7/9/2023 19:20 (7:20 PM) - Wasted. 7/9/2023 19:24 (7:24 PM) 7/10/2023 2100 (9:00 PM) 7/11/2023 2100 (9:00 PM) LVN 8 stated, medication card for Zolpidem 5 mg should have been removed from the medication cart as the medication has been discontinued by the physician. LVN 8 stated, discontinued medications are to be given to Director of Nursing (DON) as soon as the order is discontinued by a physician. LVN 8 stated, "I cannot answer this one why it wasn't removed". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 69 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 26's MAR for the months of 6/2023 and 7/2023, there was no documentation of Zolpidem being ordered or administered on the MAR on 6/27/2023, 6/29/203, 7/9/2023, 7/10/2023, or 7/11/2023. During an interview on 1/10/2024 at 3:02 PM with Assistant Director of Nursing (ADON), ADON stated, discontinued medications are given to DON or ADON if DON is not at the facility. ADON stated, if the medication is discontinued on a weekend, then medication is expected to be given to ADON or DON on Monday followed by the weekend. During an interview on 1/10/2024 at 3:20 PM with DON, DON stated, the staff is supposed to give DON the discontinued controlled medications immediately, but also may give them up to 72 hours after the discontinuation date. DON stated, nurses should have given any controlled medications not used within few months. DON stated the risk of having a discontinued medication in the medication cart is a possibility for someone to misuse the medication or cause drug diversion. During a review of "RX 1 (Facility's initial dispensing pharmacy) - Authorization to dispense a Schedule III-V Controlled Substance", dated 4/28/2023, the form indicated, Zolpidem 5 mg order for Resident 26 was requested for a quantity of 30 with four refills. During a review of document, titled "RX 1", the document indicated a prescription number with Resident 26's name with status delivered on 4/29/2023 at 17:00 (5:00 PM). During a phone interview on 1/11/2024 at 4:45 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 70 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE PM with Registered Pharmacist (RPh) 1 at RX 1, RPh 1 stated that RX 1 is a specialty pharmacy and do not have Resident 26's record for Zolpidem 5 mg. RPh 1 stated this call should go to RX 2 (facility's dispensing pharmacy after merger with RX 1) where the prescription was filled. During a phone interview on 1/11/2024 at 5:00 PM with RPh 2 at RX 2, RPh 2 stated, "there was merge between RX 1 and RX 2 and when the merge happened, RX 2 only has their orders, not what was at RX 1". RPh 2 stated, "RX 2 has stopped servicing this facility on 12/3/23, RX 2 didn't dispense the medication to the facility and are unable to see records from RX 1." During a phone interview on 1/11/2024 at 5:15 PM with Data Entry Supervisor (DE 2), DE 2 confirmed that there are no dispensing records for Resident 26's Zolpidem at RX 2. During a review of the facility's P&P titled, "Pharmacy Services, Physician Orders," dated 05/2019, the P&P indicated, "No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses." 2b. During a review of Resident 310's Admission Record, (a document containing demographic and diagnostic information), dated 1/10/2024, the admission record indicated that the resident was admitted to the facility originally on 12/11/2023 with diagnosis including chronic pain syndrome. During a concurrent observation and interview on 1/10/2024 at 11 AM, with Licensed Vocational Nurse (LVN) 2, of the Medication Cart 1A, Resident 310's medication card for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 71 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Methadone 10 mg indicated quantity of 13 tablets remaining and the CDR indicated a quantity of 14 tablets remaining. CDR indicated last administration to be on previous day, 1/9/2024 at 5:00 PM. LVN 2 stated she was nervous and forgot to document on CDR on 1/10/2024 after one tablet of Methadone 10 mg was removed from the medication card and after Methadone was administered to Resident 310. LVN 2 stated CDR should match MAR and EHR to ensure appropriate medication administration to the resident. LVN 2 stated administration should be documented to account for drug and to prevent medication errors or duplicate administration by another nurse, that can put resident at risk for drug overdose and misuse. During a concurrent interview and record review on 1/10/2024 at 11:24 AM with LVN 2, EHR for Resident 310, dated 1/10/2024, LVN 2 reviewed the EHR. The EHR indicated Methadone HCl Oral Tablet 10 mg was scheduled for 9:00 AM on 1/10/2024, documented as administered on 1/10/2024 at 9:51 AM. MAR indicated with a check mark that Methadone 10 mg was administered by LVN 2 on 1/10/2024 at 9:00 AM. LVN 2 stated that the medication administration was recorded on the EHR, but she forgot to document on CDR. During a review of the facility's P&P titled, "Controlled Substance Storage- Medication Storage in the Facility," revised date January 2018, the P&P indicated, "The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications as ordered and the goal of therapy is met ... ...Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Documentation Examples, Form 12: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 72 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE INDIVIDUAL RESIDENT'S CONTROLLED SUBSTANCE RECORD." 3 .During a review of Resident 90's "Admission Sheet," undated, indicated Resident 90 was admitted to the facility in 6/2020 with diagnoses including but not limited to the following: insomnia (inability to sleep), anemia (low levels of red blood cells in the blood), and rectal abscess (collection of pus that develops near the rectum). During a review of Resident 90's "History and Physical (H&P)," dated 8/1/2023, it indicated Resident 90 has the capacity to understand and make decisions. During a review of Resident 90's "Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities and identifies health problems)," dated 12/22/2023 indicated Resident 90 required maximal assistance with sitting to lying down, dressing lower the lower body (from the waist and below) and hygiene with toileting (ability to maintain personal hygiene). During a review of Resident 90's "Order Summary Report," it indicated Resident 90 had an active order for Xanax 0.5 milligrams (mg) dated 12/13/2023 to be used for anxiety and to be given every eight hours as needed. During a review of Resident 90's MAR, dated 10/2023, it did not indicate Xanax 0.5 mg was given to Resident 90 on 10/26/2023 at 12:00 AM and 6:00 AM. During a review of Resident 90's "Controlled Substance Count Sheet," dated 10/26/202311/23/2023, it indicated Xanax 0.5 mg was dispensed on 10/26/2023 at 12:00 AM and 6:00 AM but missing two nurse's signatures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 73 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/11/2024 at 10:22 AM with LVN (Licensed Vocation Nurse) 3, LVN 3 stated nurses need to date, time, and sign the Controlled Medication Count sheet and document in the resident's MAR each time a controlled medication is administered. LVN 3 also stated missing signatures can put the resident at risk for accidental double dosing as it would be shown as not given on the resident's chart. During an interview on 1/11/2024 at 10:39 AM with Director of Nursing (DON), DON stated there were two missing signatures on the Controlled Medication Count sheet for Xanax on 10/26/2023 at 12:00 AM and 6:00 AM, and no documentation on Resident 90's MAR indicating Xanax was administered on 10/26/2023 at 12:00 AM and 6:00 AM. DON stated the resident would be at risk for double dosing, and further stated there is no clear indication if Xanax was given to resident. DON also stated there is no excuse to not sign the Controlled Medication Count Sheet and to document in the resident's MAR. During a concurrent interview and record review on 1/11/2024 at 12:40 PM with the DON, the facility's policy and procedure (P&P) titled, "Controlled Substance Storage," revised 1/2018, was reviewed. It indicated any discrepancy in controlled substance counts are reported to the DON immediately. DON stated the Licensed Vocational Nurse (LVN) LVN failed to report the discrepancy to DON, and an investigation should have been started immediately. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 74 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F757 Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/05/2024 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure two of two residents (Resident 90 and 154) were free of unnecessary medications in accordance to the facility's policy and procedure and residents care plan. The facility failed to: 1a. For Resident 90, there was no clinical justification in the resident's medical record for the physician's order that GDR (Gradual Dose Reduction-a process to lower dose of medication to determine if symptoms can be managed at a lower dose) was not attempted due to contraindication for Ambien (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 75 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication to treat insomnia [the inability to fall asleep]) that Resident 90 has been receiving Ambien since 3/23/2023. 1b. Ensure Resident 90 who was receiving Xanax (medication to treat anxiety) and Norco (a medication to treat pain) were monitored for side effects ( undesired effect of medication). These failures had the potential for Resident 90 to experience adverse side effects related to Ambien, Xanax, and Norco such as increased sleepiness, drowsiness, lower blood pressure and decreased ability to breath. 2. For Resident 154 was monitored for bruising and bleeding while receiving Eliquis (apixaban, used to treat or prevent deep venous thrombosis [DVT, a condition in which harmful blood clots form in the blood vessels of the legs]). This deficient practice increased the risk of Residents 154 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as heavy bleeding and bruising. Findings: During a review of Resident 90's "Admission Sheet," undated, it indicated Resident 90 was admitted to the facility in 6/2020 with diagnoses including but not limited to the following: insomnia, anemia (low levels of red blood cells in the blood), and rectal abscess (collection of pus that develops near the rectum). During a review of Resident 90's "History and Physical (H&P)," dated 8/1/2023, it indicated Resident 90 has the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 76 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 90's "Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities and identifies health problems)," dated 12/22/2023, indicated Resident 90 required maximal assistance with sitting to lying down, dressing lower the lower body (from the waist and below) and hygiene with toileting (hygiene performed after urine and stool movement). 1. During a review of Resident 90's "Order Summary Report," it indicated Resident 90 had an active order for Ambien 10 milligrams (mg) dated 3/23/2023 to be given every night for insomnia. During a review of Resident 90's "Medication Administration Record (MAR)," it indicated Resident 90 has been receiving Ambien every night from 10/2023 to 12/2023 at 9:00 PM. During a review of Resident 90's "Note to Attending Physician/Prescriber," dated 10/11/2023, it indicated GDR is clinically contraindication, benefits outweigh the risks. During an interview with on 1/11/2024 at 9:34 AM with Pharmacy Consultant (PC), PC stated there should be proper notes and documentation monthly from the prescribing doctor indicating what is clinically contraindicated for the GDR of Ambien. During a concurrent interview and record review on 1/11/2024 at 10:40 AM with DON, Resident 90's "Note to Attending Physician/Prescriber" was reviewed. It indicated GDR for Ambien was clinically contraindicated. DON stated it does not list the clinical justification and it should clearly state why the GDR for Ambien is contraindicated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 77 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 90's "Psychiatric GDR Progress Notes," dated 12/13/2023, 9/13/2023, and 7/12/2023 indicated the GDR for Ambien is contraindicated at this time, the benefit of continued use outweighs the perceived risk. During a review of Resident 90's "Medication Management Note," dated 4/19/2023, it indicated the physician wrote "no GDR attempts for Ambien were made." During a review of facility's policy and procedure titled, "Psychotropic Drug Use," undated, it indicated quarterly thereafter, or with any significant change in condition, the residents will be calendared by the Social Services Director (SSD) for referral to the Psychotropic Drug Review Committee to assess for continued need/justification of the medication and possible Gradual Dose Reduction. 2. During a review of Resident 90's "Order Summary Report," it indicated Resident 90 had an active order for the following medications: Xanax 0.5 mg dated 12/13/2023 to be given every eight hours as needed for anxiety. Norco 10-325 mg dated 2/29/2023 and to be given every six hours for pain management. It further indicated Resident 90 had an active order dated 9/28/2023 to monitor for side effects of anti-anxiety medications, such as, sedation (drug-induced depression of consciousness, but respond purposefully to repeated or painful stimuli), drowsiness (sleepiness), ataxia (poor muscle control), dizziness, nausea, confusion, and nasal congestion (stuffy nose). It also indicated Resident 90 had an active order dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 78 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/6/2022 to monitor every shift for side effects of hypnotic/sedative medications (used to reduce anxiety and induce sleep), such as, sedation, drowsiness, ataxia, and morning hangover (next-day drowsiness). During a review of Resident 90's "Medication Administration Record (MAR)," it indicated Xanax and Norco were given within one hour of administration on the following days: On 12/31/2023, Norco was given at 12:00 AM and Xanax was given at 12:22 AM. On 1/1/2024, Norco was given at 12:00 AM and Xanax was given at 12:18 AM. On 1/2/2024, Norco was given at 12:00 AM and 6:00 AM, Xanax was given at 12:50 AM and 6:50 AM. On 1/5/2024, Norco was given at 12:00 AM and 6:00 AM, Xanax was given at 12:58 AM and 6:58 AM. On 1/7/2024, Norco was given at 6:00 AM, and Xanax was given at 6:35 AM. On 1/8/2024, Norco was given at 12:15 AM and 6:20 AM, Xanax was given at 12:50 AM and 6:50 AM. On 1/9/2024, Norco was given at 12:00 AM and Xanax was given at 12:50 AM. During an interview on 1/11/2024 at 10:22 AM with LVN (Licensed Vocational Nurse) 3, LVN 3 stated it is best nursing practice to separate Xanax and Norco at least 1 hours apart. LVN 3 stated the resident would be at risk for respiratory depression (breathing too slowly or shallowly leading up to carbon dioxide build up in the blood) if Xanax and Norco are given FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 79 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE together. LVN 3 further stated there is no order to monitor for respiratory depression for Resident 90, LVN 3 stated there should be an order as Resident 90 is receiving Xanax and Norco. During concurrent interview and record review on 1/11/2024 at 10:35 AM with the Director of Nursing (DON), Resident 90's "MAR" and "Order Summary" were reviewed. The MAR indicated Norco and Xanax were administered within one hour of each medication on the following days: 12/31/2023 1/1/2024 1/2/2024 1/5/2024 1/7/202 1/8/2024 1/9/2024 DON stated Norco and Xanax should not be given within one hour of each other, and further stated there is no orders to monitor for respiratory depression. DON stated it should be monitored as the resident is at risk for an adverse side effect if Xanax and Norco are given together. During a review of "Black Box Warning Details," undated, indicated the use of opioids (powerful pain reducing medications) with benzodiazepines (medications that treat anxiety) or other Central Nervous System (CNS, made up of nerves cells that send information through the spinal cord to the brain) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 80 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. 3.A review of Resident 154's Admission Record indicated an admission to the facility on 12/01/2023 with diagnoses that included encounter for surgical aftercare following surgery, malignant neoplasm of colon (cancer that begins in the last part of the digestive tract (colon/large intestine), and colostomy (an operation that creates an opening for the colon through the abdomen). A review of Resident 154's History and Physical Assessment dated 12/8/2023 indicated Resident 154 had the capacity to understand and make decisions. A review of Resident 154's Order Summary Report dated 12/05/2023, indicated a physician order was made for Eliquis Oral Tablet 5 milligrams (mg, unit of measure) (Apixaban), give 5 mg by mouth two times day for DVT prophylaxis (measures designed to preserve health and prevent the spread of disease). During an interview with the Administrator (ADM) on 1/11/2024 at 8:35 AM, the ADM stated there is no policy for the use of anticoagulants. During a concurrent interview and record review of Resident 154's Medication Administration Record (MAR) with the Minimum Data Set (MDS) Nurse on 1/11/2024 at 11:25 AM, MDS nurse stated she could not find documented evidence in the MAR during 12/05/2023 to 12/20/2023, that licensed nurses monitored the resident adverse reaction of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 81 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Eliquis such as bleeding/bruising. The MDS nurse stated it is important to monitor for signs and symptoms of bleeding, bruising, and discoloration to notify the doctor of any changes. During an interview with the Director of Nursing (DON) on 1/11/2024 at 11:50 AM, the DON stated it is important to monitor for increase of bruising or bleeding when a resident is using an anticoagulant. The DON stated the facility does not have a policy for the use of anticoagulants. The DON stated if a resident experiences bruising or bleeding, it would be documented on a change of condition note or progress note. The DON stated sometimes it would be documented on the MAR and if it was any noticeable increase in bleeding, the nurses will notify the doctor immediately.

F760 SS=E Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 02/05/2024 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to at least four out of 11 residents (Resident 43, 65, 103 and 113) whose insulin was found to be expired during the inspection of three of five medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). These failures resulted in residents (Resident 43, 65, 103 and 113) receiving expired insulin doses that could affect the effectiveness of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 82 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication to lower the blood sugar level and the potential to result in serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death. Findings: a. During a review of Resident 43's Admission Record, (a document containing demographic and diagnostic information), dated 1/8/2024, the admission record indicated that the resident was admitted on 3/14/2023 with diagnoses including Type 2 Diabetes Mellitus (a medical condition characterized by the inability to control blood sugar) with foot ulcer and type 2 diabetes mellitus with diabetic chronic kidney disease (a condition in which the kidneys are damaged). During a review of Resident 43's History and Physical, dated 3/15/2023, the document indicated resident has the capacity to understand and make decisions. During a review of Resident 43's Order Summary Report (a document containing a summary of all active physician orders), dated 1/8/2g.;]024, the order summary report indicated, "Humalog injection solution 100 units/milliliters (mL), inject as per sliding scale (insulin doses based on blood glucose level): if 151-200 = 2 units; 201-250 =4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; IF BLOOD GLUCOSE GREATER THAN 400, GIVE 12 UNITS RECHECK AND CALL MD (Medical Doctor), subcutaneously (under the skin) before meals and at bedtime for DIABETES IF BLOOD GLUCOSE LESS THAN 70 AND CONSCIOUS, GIVE INSTAGLUCOSE PO (BY MOUTH) AND RECHECK AFTER 15 MINUTES. IF INEFFECTIVE AND/OR UNCONSCIOUS (HYPOGLYCEMIC), GIVE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 83 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE GLUCAGON 1 MG IM X1, RECHECK AND CALL MD." During an observation on 1/8/2024 at 12:19 PM, Licensed Vocational Nurse (LVN) 6, LVN 6 stated she performed blood glucose check on Resident 43 and the reading was 234 milligrams (mg) per deciliters (dL) (per [American Diabetes Association] (ADA): normal blood glucose level less than 100 mg/dL), and will administer four units of Humalog under the skin based on sliding scale instructions. LVN 6 showed insulin vial after administration which was labeled with an opened date of 12/6/23. Per the manufacturer's product labeling, once opened or stored at room temperature, Humalog insulin must be used within 28 days or be discarded. LVN 6 confirmed that Resident 43's Humalog insulin expired on 1/3/2024 and should have been removed from the medication cart. LVN 6 stated that once expired, insulin would not be effective if administered to residents to control blood sugar. During a review of Resident 43's Medication Administration Record (MAR - log of all medications given to resident), dated 1/1/2024 to 1/8/2024, the MAR indicated Resident 43 was administered 13 doses of expired Humalog insulin on: 1/4/2024 at 11:30 AM, 4:30 PM and 9:00 PM 1/5/2024 at 11:30 AM and 4:30 PM 1/6/2024 at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM 1/7/2024 at 11:30 AM and 9:00 PM 1/8/2024 at 6:30 AM and 11:30 AM b. During a review of Resident 103's Admission Record, dated 1/8/2024, the admission record indicated that the resident was admitted on 3/2/2022 with diagnoses including Type 2 Diabetes Mellitus with unspecified complications and long term (current) use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 84 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE insulin. During a review of Resident 103's Order Summary Report, dated 1/8/2024, the order summary report indicated, "Admelog Injection Solution 100 units/mL (Insulin Lispro) Inject as per sliding scale: if 151-200 = 1 UNIT; 201-250 = 2 UNITS; 251-300 = 3 UNITS; 301-350 = 4 UNITS; 351-400 = 5 UNITS IF BSL IS GREATER THAN 400 - GIVE 6 UNITS. RECHECK BSL AFTER 15 MINUTES AND CALL MD., subcutaneously (under the skin) before meals and at bedtime for DIABETES. IF BSL IS LESS THAN 70 AND CONSCIOUS OR NO CHANGE IN LOC, GIVE INSTAGLUCOSE PO x 1. RECHECK BSL AFTER 15 MINUTES. IF INEFFECTIVE, AND OR UNCONSCIOUS (D/T HYPOGLYCEMIA [low blood sugar]) GIVE GLUCAGON 1MG IM (intramuscularlyinto the muscle) x 1 AND CALL MD". During an interview on 1/8/2024 at 12:19 PM with LVN 6, LVN 6 stated Resident 103's Insulin Lispro was labeled with an open date of 12/6/2023, which expired on 1/3/2024 and should have been removed from the medication cart. LVN 6 stated that once expired, the insulin would not be effective if administered to residents to control blood sugar. During a review of Resident 103's MAR, dated 1/1/2024 to 1/8/2024, the MAR indicated Resident 103 was administered 12 doses of expired Insulin Lispro on: 1/4/2024 at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM 1/5/2024 at 11:30 AM, 4:30 PM and 9:00 PM 1/6/2024 at 4:30 PM and 9:00 PM 1/7/2024 at 11:30 AM, 4:30 PM and 9:00 PM c. During a review of Resident 113's Admission Record, dated 1/8/2024, the admission record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 85 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated that the resident was admitted on 10/3/2023 with diagnoses including Type 2 Diabetes Mellitus with unspecified complications and long term (current) use of insulin. During a review of Resident 113's History and Physical record, dated 10/5/2023, the record indicated resident has the capacity to understand and make decisions. During a review of Resident 113's Order Summary Report, dated 1/8/2024, the order summary report indicated, "Insulin Aspart Injection Solution 100 UNITS/ML (Insulin Aspart) Inject per sliding scale: if 151-200 = 1 UNIT; 201-250 = 2 UNITS; 251-300 = 3 UNITS; 301-350 = 4 UNITS; 351-400 = 5 UNITS IF BS IS >400, GIVE 6 UNITS. RECHECK AFTER 15 MINS THEN CALL/NOTIFY MD., subcutaneously before meals and at bedtime for DM IF BLOOD GLUCOSE LESS THAN 70 AND CONSCIOUS GIVE INSTALGUCOSE PO, RECHECK AFTER 15 MINUTES, IF INEFFECTIVE AND/OR UNCONSCIOUS (D/T HYPOGLYCEMIA). GIVE GLUCAGON 1MG IM X1, RECHECK AND CALL MD". During an interview on 1/8/2024 at 12:19 PM with LVN 6, LVN 6 stated Resident 113's Insulin Aspart was labeled with an open date of 12/3/2023, which expired on 12/31/2023 and should have been removed from the medication cart. LVN 6 stated that once expired, the insulin would not be effective if administered to residents to control blood sugar. During a review of Resident 113's MAR, dated 1/1/2024 to 1/8/2024, the MAR indicated Resident 113 was administered six doses of expired Insulin Aspart on: 1/1/2024 at 6:30 AM 1/5/2024 at 11:30 AM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 86 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/6/2024 at 11:30 AM, 4:30 PM and 9:00 PM 1/7/2024 at 9:00 PM d. During a review of Resident 65's Admission Record, dated 1/8/2024, the admission record indicated that the resident was admitted on 9/16/2023 with diagnoses including Type 2 Diabetes Mellitus with unspecified complications and Type 2 Diabetes Mellitus with diabetic neuropathy (nerve damage), unspecified. During a review of Resident 65's Order Summary Report, dated 1/8/2024, the order summary report indicated, "Insulin Lispro Injection Solution 100 UNITS/ML (Insulin Lispro) Inject as sliding scale: if 151-200 = 1 UNIT; 201-250 = 2 UNITS; 251-300 = 3 UNITS; 301-350 = 4 UNITS; 351-400 = 5 UNITS IF BSL IS GREATER THAN 400, GIVE 6 UNITS. RECHECK BSL AFTER 15 MINUTES AND CALL MD., subcutaneously before meals and at bedtime for DIABETES. IF BSL IS LESS THAN 70 AND CONSCIOUS OR NO CHAGE IN LOC, GIVE INSTAGLUCOSE PO x 1. RECHECK BSL AFTER 15 MINUTES. IF INEFFECTIVE AND OR UNCONSCIOUS (D/T HYPOGLYCEMIA), GIVE GLUCAGON 1MG IM x 1 AND CALL MD". During a concurrent inspection and interview of Medication Cart 1B on 1/8/2024 at 12:58 PM with LVN 2, LVN 2 stated Resident 65's Insulin Lispro has written open date of 12/1/2023 which expired on 12/29/2023 and should have been removed from the medication cart. LVN 2 stated "once you open the insulin, the life is only a month, if it is used more than a month it's not as potent". During a review of Resident 65's MAR, dated 12/1/2023 to 1/8/2024, the MAR indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 87 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 65 was administered five doses of expired Insulin Lispro on: 12/30/2023 at 4:30 PM 12/31/2023 at 4:30 PM 1/2/2024 at 9:00 PM 1/3/2024 at 9:00 PM 1/5/2024 at 4:30 PM During an interview on 1/8/2024 at 4:16 PM with Director of Nursing (DON), DON stated nurses should be checking for expiration and dating of insulin in medication carts. DON stated she usually spot checks the medication carts but does not remember the last time when she checked the medications in the cart. DON stated pharmacy consultant spot checks medications in the medication carts but was unable to provide any documentation of medication carts being checked by pharmacy or by DON. DON stated nurses were supposed to discard opened insulin containers, vials, and pens after 28 days. DON stated the expired insulin can affect the potency and dose effectiveness of the insulin. DON stated if residents are administered expired insulin, it can result in residents suffering hyperglycemia (high blood sugar) which can lead to tremors, coma, hospitalization, and other complications. During a review of the facility's policy and procedure (P&P) titled, "Medication Storage in the Facility," dated 01/2018, the P&P indicated, "When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) the nurse shall place a "date opened" sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a "date opened" and "expiration" notation line) The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 88 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (See Appendix 28 - Medications with shortened expiration dates). The nurse will check the expiration date of each medication before administering it. All expired medications will be removed from the active supply." During a review of the facility's P&P titled, "Appendix 28: Medications with Shortened Expiration Dates", dated 12/2022, the P&P provided by the facility was unclear and was marked as "Example".

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 02/05/2024 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 89 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, and record review, the facility failed to: 1. Ensure expired insulin (a medication used to treat high blood sugar) was removed and discarded for 11 residents (Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident) in three of five inspected medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). 2. Ensure safe, secured, and limited access to prescription medication Keppra ([Generic name- Levetiracetam], medication used to treat seizure condition) for Resident 116. These failures increased the risk that: Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death; Resident 116's seizure medication may not be administered as ordered, and increase the risk of unintended access, potential for misuse, and medication errors. Findings: 1. During an observation on 1/8/2024 at 12:19 PM, Licensed Vocational Nurse (LVN) 6, LVN 6 stated she performed blood glucose check on Resident 43 and the reading was 234 and will administer four units of Humalog (Generic name - Insulin Lispro) under the skin based on sliding scale instructions. LVN 6 showed insulin vial after administration which was labeled with an opened date of 12/6/2023. Per the manufacturer's product labeling, once opened or stored at room temperature, Humalog insulin must be used within 28 days or be discarded. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 90 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 6 confirmed that the unlabeled and expired insulin should have been removed from the medication cart on or by 1/3/2024. LVN 6 stated that once expired, insulin would not be effective if administered to residents to control blood sugar. 1a. During an inspection of Medication Cart 2A on 1/8/2024 at 12:22 PM, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications, or not labeled with resident name. a. Humalog (Generic name - [Insulin Lispro]) insulin vial for Resident 43 with an open date of 12/6/2023. Per the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Humalog insulin must be used within 28 days or be discarded. Resident 43's Humalog insulin expired on 1/3/2024. b. Humalog KwikPen for Resident 103 with an open date of 12/6/2023. Per the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Humalog insulin must be used within 28 days or be discarded. Resident 103's Humalog KwikPen expired on 1/3/2024. c. Novolog Flexpen (Generic name - [Insulin Aspart]) is a small, lightweight disposable pen that is prefilled with insulin for Resident 113 with an open date of 12/3/23. Per the manufacturer's product labeling, once opened, Novolog insulin can be stored at room temperature for up to 28 days. Resident 113's Novolog Flexpen expired on 12/31/2023. d. Humulin KwikPen 70/30 (Generic name FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 91 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE [70% Insulin Isophane Human and 30% Insulin Human]) for Resident 31 with no open date. e. Humulin KwikPen 70/30 with no open date and no resident name. Per the manufacturer's product labeling, when stored at room temperature, Humulin KwikPen 70/30 can only be used for a total of 10 days including both not in-use (unopened) and inuse (opened) storage time. 1b. During an inspection of Medication Cart 2B on 1/8/2024 at 1:00 PM, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications, or not labeled with resident name. a. Humalog KwikPen for Resident 127 with no open date. Per the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Humalog KwikPen must be used within 28 days or be discarded. b. Humulin R for Resident 86 with unclear open date. Per the manufacturer's product labeling, in-use (opened) vial must be used within 31 days or be thrown out. c. Lantus (Generic name - [Insulin Glargine]) Solostar Pen for Resident 127 with no open date. d. Lantus Solostar Pen for Resident 27 with no open date. Per the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86°F [30°C]) and opened / in-use pen must be used within 28 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 92 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent interview on 1/8/2024 at 1:00 PM with LVN 4, LVN 4 confirmed that expired and insulin with no dates have a risk for residents not getting proper dosage. LVN 4 stated insulin loses potency if expired and administered. 1c. During an inspection of Medication Cart 1B on 1/8/2024 at 12:58 PM, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications. a. Humalog KwikPen for Resident 260 with an open date of 12/2/2023. Per the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Humalog KwikPen must be used within 28 days or be discarded. Resident 260's Humalog KwikPen expired on 12/30/2023. b. Lantus Solostar Pen for Resident 260 with no open date. Per the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86°F [30°C]) and opened / in-use pen must be used within 28 days. During a concurrent interview on 1/8/2024 at 1:00 PM with LVN 2, LVN 2 stated, "resident has not used this pen in the last few days, usually the nurse is responsible for changing the pens." c. Humalog KwikPen for a discharged resident with no open date. Per the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Humalog KwikPen must be used within 28 days or be discarded. d. Humalog KwikPen for Resident 65 with an open date of 12/1/2023. Per the manufacturer's product labeling, once opened / in-use or once FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 93 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stored at room temperature, Humalog KwikPen must be used within 28 days or be discarded. Resident 65's Humalog KwikPen expired on 12/29/2023. e. Basaglar KwikPen (Generic name - [Insulin Glargine]) for Resident 3 with no open date. Per the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Basaglar KwikPen must be used within 28 days or be discarded. During a concurrent interview on 1/8/2024 at 1:02 PM with LVN 2, LVN 2 stated, "once you open the insulin, the life is only a month, if it is used more than a month it's not as potent." During an interview on 1/8/2024 at 4:16 PM with Director of Nursing (DON), DON stated nurses should be checking for expiration and dating of insulin in medication carts. DON stated she usually spot checks the medication carts but does not remember the last time when she checked the medications in the cart. DON stated pharmacy consultant spot checks medications in the medication carts but was unable to provide any documentation of medication carts being checked by pharmacy or by DON. DON stated nurses were supposed to discard opened insulin containers, vials, and pens after 28 days. DON stated the expired insulin can affect the potency and dose effectiveness of the insulin. DON stated if residents are administered expired insulin, it can result in residents suffering hyperglycemia (high blood sugar) which can lead to tremors, coma, hospitalization, and other complications. During a review of the facility's policy and procedure (P&P) titled, "Medication Storage in the Facility," dated 01/2018, the P&P indicated, "When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) the nurse shall place a "date opened" sticker on the medication and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 94 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a "date opened" and "expiration" notation line) The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating (See Appendix 28 - Medications with shortened expiration dates). The nurse will check the expiration date of each medication before administering it. All expired medications will be removed from the active supply." During a review of the facility's P&P titled, "Appendix 28: Medications with Shortened Expiration Dates", dated 12/2022, the P&P provided by the facility was unclear and was marked as "Example". 2. During a review of Resident 116's Admission Record, (a document containing demographic and diagnostic information), dated 1/10/2024, the admission record indicated the resident was originally admitted to the facility on 8/31/2012, with a readmission date of 10/1/2023, with diagnosis including other seizures. During a review of Resident 116's Order Summary Report (a document containing a summary of all active physician orders), dated 1/10/2024, the document indicated order for Levetiracetam oral solution 100 milligrams (mg) per milliliters (mL), Give 15 mL via G-Tube two times a day for seizure disorder. During an observation on 1/8/2024 at 12:40 PM on the nurse's station counter, there was an unattended bottle of Keppra (Generic nameLevetiracetam) 100 mg/mL Oral Solution for Resident 116, which was easily accessible to public and residents in the facility. During a concurrent interview with LVN 6, LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 95 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6 stated she did not know how or who left the medication like that on the nurse's station. LVN 6 confirmed that this medication should not be left unattended. LVN 6 stated there is a risk that resident may not receive the medication dose as prescribed, or the medication could be misused or lead to medication errors. During a review of the facility's policy and procedure (P&P) titled, "Medication Storage in the Facility," dated 01/2018, the P&P indicated, "Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications".

F809 SS=D Frequency of Meals/Snacks at Bedtime CFR(s): 483.60(f)(1)-(3)

F809 02/05/2024 §483.60(f) Frequency of Meals §483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. §483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. §483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 96 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to serve lunch meal service at 12PM as indicated in the facility's policy and procedure titled, "Mealtime Service" to three of six sampled residents (Residents 25, 59, and 124). These deficient practices resulted in three residents not receiving meals at regularly scheduled time, in which the resident's complained of hunger. In addition, the residents who are receiving medications that lowers the blood sugar level could cause dangerously low blood sugar levels or not receive medications with meals as prescribed by the physician, which could compromise the resident's wellbeing. Findings: 1. A review of Resident 25's Admission Record indicated the facility admitted Resident 25 on 2/8/2023 with diagnoses that included dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), and diabetes (a group of diseases that result in too much sugar in the blood. A review of Resident 25's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/5/2023 indicated Resident 25 was independent in movement of the upper extremities (shoulder, elbow, wrist, hand) but required substantial/maximal assistance (helper does more than half the effort) for eating, hygiene, bathing, dressing, repositioning in bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 97 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 25's History and Physical, dated 2/10/2023, indicated Resident 25 had fluctuating (changing) capacity to make decisions. 2. A review of Resident 59's Admission Record indicated the facility admitted Resident 59 on 6/15/2022 with diagnoses that included morbid obesity (a serious health condition that results from an abnormally high body mass that is diagnosed by having a body mass index (BMI) greater than 40), hemiplegia (paralysis of one side of the body), and diabetes. A review of Resident 59's MDS, dated 12/5/2023 indicated Resident 59 required set up or clean-up assistance with eating and personal hygiene. It also indicated that Resident 59 required substantial/maximal assistance with dressing, repositioning in bed and was completely dependent with toileting. A review of Resident 59's History and Physical dated 5/24/2023 indicated that Resident 59 had the capacity to make decisions. 3. A review of Resident 124's Admission Record indicated the facility admitted Resident 124 on 2/23/2023 with diagnoses that included dysphagia, dementia (a group of thinking and social symptoms that interferes with daily functioning) and adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive (feeling severe sadness and hopelessness) symptoms, and impaired immune function (body's ability to fight infection). A review of Resident 124's MDS, dated 12/29/2023 indicated Resident 124 was independent in movement of the upper FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 98 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE extremities (shoulder, elbow, wrist, hand) but dependent of staff (helper does all the work) for eating, hygiene, bathing, dressing, repositioning in bed. A review of Resident 124's History and Physical dated 10/1/2023 indicated that Resident 124 did not have the capacity to make decisions. During an interview and concurrent observation on 1/8/2024 at 12:53 PM, CNA 9 stated that the last set of lunch trays usually comes out about this time. During an interview and concurrent observation on 1/8/2024 at 12:58 PM, Certified Nursing Assistant (CNA) 8 stated that Resident 25 requires feeding assistance and usually gets meal tray around noon. During an interview and concurrent observation on 1/8/24 at 1:03 PM, Resident 59 was observed receiving a lunch tray and the resident stated that he usually gets his lunch tray around 12:30 PM, which was late. During an interview and concurrent observation on 1/10/2023 at 12:47 PM, CNA 10 was bringing Resident 124's lunch tray and stated that the lunch service was late. During an observation on 1/10/2024 at 12:52 PM, a meal cart with lunch trays were observed leaving the kitchen for distribution to the nursing stations. During an interview and concurrent observation on 1/10/2024 at 1:01 PM, Resident 124 was observed receiving his lunch tray. The resident stated lunch is late and that he was hungry and waiting. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 99 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/11/204 at 9:15 AM, Dietary Supervisor (DS) stated that the facility does not have a time limit for the meal trays to come out (for service). DS stated that they (the kitchen) try to get the meals out as soon as possible but sometimes it just takes longer. DS stated normally it takes one hour to one hour and 15 minutes (after the start of mealtime) to service all the residents. DS stated there is no policy to limit how long it takes to serve residents their meals. During an interview on 1/11/2024 at 12:38 PM, Director of Nursing (DON) stated that the facility does not have a policy for how long the kitchen must serve meals. There is no time limit to how long they can take. During an interview on 1/11/2024 at 12:38 PM, Administrator (ADM) stated that they are a large facility and that it could take an hour to get the trays out of the kitchen. ADM stated that the 45 minutes indicated in the policy was for how long the staff must serve the meal once the kitchen has released the trays. When the ADM was asked what a reasonable cut off time for when the meals should should be served to the residents, the ADM stated one hour to one and a half hours past start of mealtime. ADM stated the facility does not have policy for how long it should take before a resident receives their meal after the start of mealtime. During an interview on 1/11/24 at 12:40 PM, DON stated that mealtimes could interfere or cause issues if it is more than an hour late to the residents that have medications that are mealtime dependent. During an interview on 1/11/2024 at 1:44 PM, Licensed Vocational Nurse 6 (LVN6) stated that medications that were given before lunch were usually given around 11:30 AM. LVN 6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 100 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated that if the meal was very late it could affect things like the blood sugar in the resident. LVN 6 stated that sometimes the residents were unhappy when lunch was late. During an interview on 1/11/2024 at 2PM., Licensed Vocational Nurse 10 (LVN10) stated that the Medication Administration Record (a list of medications with times and signature for distribution) indicated the time of the medication to be given and that medication administration times were indicated in the physician's orders. LVN 10 stated that if it is a medication that needs to be given to the resident before meals at lunch time, the usual administration time was between 11:00 AM-11:30 PM, because lunch was scheduled to be served at noon. LVN 10 stated the timing of the medication in relation to the mealtime was important because it could negatively impact residents. LVN 10 stated the medication insulin (medication given to decrease blood sugar level) was an example. If insulin was given too early (before a meal) it could cause the resident to become hypoglycemic (have low blood sugar). The facility provided the facility's policy and procedure titled, "Meal Service" dated 2023, indicated that lunch time is at 12 PM. The policy also indicated that, "meals are provided to residents within 45 minutes," and that nursing personnel will serve the trays immediately upon checking the tray."

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 02/05/2024 §483.60(i) Food safety requirements. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 101 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review the facility failed to: 1. Separate dented cans on the shelf in the dry food storage area. 2. Label used or opened food items with an expiration date and remove expired food items in the resident refrigerator, kitchen refrigerator, kitchen freezer and dry goods storage. 3. Ensure staff used gloves or utensils when handling and preparing food. 4. Ensure the top exterior of the ice machine was clean. These failures have the potential to expose the residents to a food borne illness (illness caused by eating dirty food; symptoms include: nausea, vomiting, diarrhea). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 102 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. During a concurrent observation and interview on 1/8/24 at 8:48 AM with Dietary Supervisor (DS) in the dry food storage room, two dented food cans were observed on the dry food shelf. DS stated the two dented cans should be placed in the dented cans area. DS also stated having dented cans on the shelves can compromise the quality of the food and be at risk for bacteria growth. During a review of the facility's P&P titled, "Food Storage-Dented Cans," undated, indicated all dented cans and rusty cans to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. 2. During a concurrent observation and interview on 1/8/24 at 8:28 AM with the DS in the kitchen refrigerator, a large plastic bin full of lettuce was observed without a label or date. The DS stated the lettuce should have been labeled. During a concurrent observation and interview on 1/8/23 at 8:35 AM with Kitchen Aide (KA) 2 in the dry food storage room, no open date labels were observed on two opened peanut butter jars on the dry food shelf. KA 2 stated two opened peanut butter jars do not have open date labels. KA 1 further stated the open date label should be placed when staff open food items to ensure the quality of the food. During an observation on 1/8/24 at 8:40 AM in the facility's freezer, the following was observed: a. an open and undated bag of pepperoni. b. an unlabeled bag of tilapia fillets. c. an unlabeled bag of corn on the cob. d. a dripping and unzipped bag of ham. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 103 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent observation and interview on 1/10/24 at 11:10 AM with Registered Nurse Supervisor (RNS) 2 in the staff lounge, the following were found inside the residents' refrigerator: a. an open bottle of cranberry juice without a date. b. a Nestle quick bottle without a date. c. an expired pack of veggie dip singles (dated 1/9/24). RNS 2 stated she does not know how long the undated food has been in the refrigerator and will throw them out immediately. RNS 2 did not know if residents can be potentially harmed by eating expired food. During a review of the facility's P&P titled, "Labeling and Dating of Foods", dated 2023, indicated newly opened food items will need to be closed and labeled with an open date and use by date. 3. During an observation on 1/9/24 at 12:15 PM in the kitchen, Cook (CK) 1 was observed picking up a quesadilla with their bare hands from the pan and placed it on a resident's meal tray. During a concurrent interview and record review on 1/9/24 at 1:30 PM with DS, the facility's policy and procedure (P&P) titled, "Food Handling", undated, was reviewed. It indicated Food and Nutrition Services personnel should never use bare hand contact with any foods, ready to eat or otherwise. DS stated CK 1 should use tongs to pick up food. DS also stated the food would be at risk for foodborne illnesses if it is handled with bare hands. 4. During a concurrent observation and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 104 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview on 1/8/24 at 8:47 AM with the DS in the kitchen, a dark black substance was observed on a towel after wiping the top of the ice machine. DS stated the exterior of the ice machine supposed to be wiped down daily.

F825 SS=D Provide/Obtain Specialized Rehab Services CFR(s): 483.65(a)(1)(2)

F825 02/05/2024 §483.65 Specialized rehabilitative services. §483.65(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speechlanguage pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident's comprehensive plan of care, the facility must§483.65(a)(1) Provide the required services; or §483.65(a)(2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facility failed to implement a physical therapy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 105 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (PT, a type of treatment to help manage movement and reduce pain in people) order for one of one sampled resident (Resident 6). This failure had the potential to result in a decline of Resident 6's mobility, activities of daily living, and overall physical and psychosocial well-being. Findings: During a review of Resident 6's Face Sheet (undated), it indicated Resident 6 was admitted on 6/27/2021 with diagnoses that included but not limited to the following: chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), abnormal posture, and generalized muscle weakness. During a review of Resident 6's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated 11/30/2023, the MDS indicated Resident 6's cognition was intact. It indicated Resident 6 required the assistance of two or more helpers for bed mobility, toilet use, and personal hygiene. It also indicated Resident 6 required maximum assistance when using a wheelchair. During an interview on 1/8/2024 at 12:15 PM with Resident 6, Resident 6 stated, she can't walk and is here is for therapy. Resident 6 stated she does not receive therapy and is now bedridden. Resident 6 expressed wanting to get up and walk. During a concurrent interview and record review on 1/11/2024 at 9:43 AM with Rehabilitation Coordinator (RC), Resident 6's physician order dated 5/9/2023, was reviewed. It indicated Resident 6 to start physical therapy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 106 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for leg weakness and difficulty with transfers. RC stated, the PT order was not implemented because it should have specified 'treatment or evaluation,' and was a (communication) issue between nursing and therapy. During a review of Resident 6's medical record from 5/9/2023 to 1/8/2024, the medical record did not indicate a physical therapy order specifying to "evaluate and treat" the resident or that the resident was screened following the PT order placement. During an interview on 1/11/2024 at 9:43 AM with Rehabilitation Coordinator (RC), RC stated, if a PT order is missed "it can make the patient weaker and weaker," and they will have more difficulty with mobility and transferring. During a review of the facility's policy and procedure (P&P) titled, "Orders for Therapy," dated 8/1/2019, indicated, "A physician's order to "Evaluate" and/or "Evaluate and Treat" is required prior to a PT, OT (occupational therapy, treatment aimed at helping people learn or regain skills of daily living after a change in ability), or SLP (speech-language pathology, therapy aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluation."

F867 SS=E QAPI/QAA Improvement Activities CFR(s): 483.75(c)(d)(e)(g)(2)(i)(ii)

F867 02/05/2024 §483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 107 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. §483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators. §483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation. §483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events. §483.75(d) Program systematic analysis and systemic action. §483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. §483.75(d)(2) The facility will develop and implement policies addressing: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 108 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. §483.75(e) Program activities. §483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problemprone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care. §483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility. §483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 109 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE section. §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop an plan, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) for identified quality of care deficiencies to pharmacy services. Cross reference to F755, F760, F761 and F757 The facility failed to: 1. Ensure licensed nursing staff administering the medications did not administer expired insulin (a medication used to treat high blood sugar) to at least four out of 11 residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 110 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Resident 43, 65, 103 and 113) whose insulin was found to be expired during the inspection of three of five medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). These failures resulted in residents (Resident 43, 65, 103 and 113) receiving expired insulin doses with the potential to result in serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death. 2. Ensure the Licensed staffs administering the medications Clarify physician orders with overlapping pain scale for one of two residents (Resident 65), which created a potential for duplication of opioid (a class of drugs associated with high potential for abuse) therapy. This failure had the potential to result in opioid overdose and increased risk for adverse consequences such as respiratory depression (trouble breathing) for Resident 65. 3. Ensure account for the use of controlled substances (medications with a high potential for abuse) for two residents (Resident 26 and Resident 310) in two out of three medication carts reviewed (Medication Cart 1A and Medication Cart 2C). These failures had the potential to result in unintended use of discontinued order of Zolpidem (a controlled substance used to treat sleep problems) for Resident 26, and Methadone (a controlled substance used to relieve chronic pain and to manage and treat opioid use disorder) for Resident 310. These failures placed the facility and Resident 26 and Resident 310 at risk for medication errors, misuse, drug loss, diversion, and accidental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 111 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE exposure to controlled substances to residents and staff. 4. Ensure expired insulin (a medication used to treat high blood sugar) was removed and discarded for 11 residents (Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident) in three of five inspected medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). 5. Ensure two of two residents (Resident 90 and 154) were free of unnecessary medications in accordance to the facility's policy and procedure and residents care plan by failing to: a. For Resident 90, there was no clinical justification in the resident's medical record for the physician's order that GDR (Gradual Dose Reduction-a process to lower dose of medication to determine if symptoms can be managed at a lower dose) was not attempted due to contraindication for Ambien (a medication to treat insomnia [the inability to fall asleep]) that Resident 90 has been receiving Ambien since 3/23/2023. b. Ensure Resident 90 who was receiving Xanax (medication to treat anxiety) and Norco (a medication to treat pain) were monitored for side effects (undesired effect of medication). These failures had the potential for Resident 90 to experience adverse side effects related to Ambien, Xanax, and Norco such as increased sleepiness, drowsiness, low blood pressure and decreased ability to breath. 2. For Resident 154 was monitored for bruising and bleeding while receiving Eliquis (apixaban, used to treat or prevent deep venous thrombosis [DVT, a condition in which harmful blood clots form in the blood vessels of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 112 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE legs]). During an interview on 1/11/24 at 4:48 PM, with the Administrator, who is member of the QAPI committee, stated the pharmacy services was part of the QAPI on March 2023 and that the facility was aware of the concerns related to pharmacy services. When asked for the QAPI plan to correct the identified deficiencies or care area concerns, the facility was unable to provide. In addition, the facility did not provide documentation if the QAPI plan for the pharmacy services were implemented and evaluated to why it was not effective to prevent the failures related to Federal Tags F755,

F760, F761 and F757. A review of the Facility's 2023 Quality Assurance and Performance Improvement (QAPI) Plan indicated involves identifying and providing needed care and services that are person centered, in accordance with the professional standards of practice that will meet each resident/ patient's physical, mental, and psychosocial needs. The QAPI plan is ongoing and comprehensive. Its purpose is to correct identified deficiencies in quality of services and put mechanisms in place so that our performance can consistently be improved. The plan involves all segments of services and types of care provided by all departments of this facility including, services that impact clinical care, quality of life, resident choice and transitions in care. The QAPI plan further indicated the "facility is committed to providing quality care and service. Through a collaborative facility-wide effort, we proactively identify issues or concerns, openly discuss them, and put together a plan to fix them." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 Facility ID: CA940000019 If continuation sheet 113 of 114 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055430 (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITTIER HILLS HEALTH CARE CENTER 10426 Bogardus Ave Whittier, CA 90603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OI2R11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000019 (X5) COMPLETE DATE If continuation sheet 114 of 114