WHITTIER, CA - State health inspectors documented multiple deficiencies at Whittier Pacific Care Center during an August 2024 complaint investigation, including failure to report and investigate a resident's fall, improper wound care practices, and inadequate infection control procedures affecting residents with drug-resistant bacterial infections.
Resident Fall Goes Unreported and Uninvestigated
One of the most serious findings involved a resident with dementia and muscle weakness who fell on August 1, 2024, but whose fall was never properly documented, investigated, or reported to medical staff or family members. The resident, who had a prior fall history dating to May 2023, slipped and fell after standing up from a shower chair while reaching for clothes in her closet. She was not wearing shoes at the time and struck her head on the floor.
Two weeks after the incident, the resident told inspectors she had experienced pain in both legs and her right hand following the fall. A nursing assistant who witnessed the aftermath confirmed finding the resident on the floor next to the shower chair after briefly turning away to move a wheelchair that was blocking the path to the bed.
Despite the facility's written protocols requiring comprehensive post-fall assessment, the incident was never entered into the resident's medical record. No incident report was completed, no physician notification occurred, and no family member was contacted. The facility failed to conduct required neurological checks, skin assessments, or pain evaluations following the fall.
The Assistant Director of Nursing acknowledged to inspectors that he was unaware of the fall until two weeks after it occurred during the state inspection. He confirmed that none of the required follow-up procedures had been completed, including the situation-background-assessment-recommendation communication form, change of condition assessment, or interdisciplinary team meeting.
According to the facility's own fall protocol policy, all accidents involving residents must be promptly reported to the administrator, physician, and responsible party. The nursing supervisor is required to initiate and document an investigation including time, date, circumstances, nature of any injury, and follow-up information. The protocol specifically requires documentation of vital signs, recent injury assessment, changes in cognition or consciousness, neurological status, pain levels, precipitating factors, and details about how the fall occurred.
The resident's care plan, last revised in August 2023, identified her as being at risk for falls due to difficulty walking, lack of coordination, muscle weakness, use of psychiatric medications, poor safety awareness, and her previous fall history. However, the plan was never updated following the August 2024 incident to address the specific circumstances or implement preventive measures.
Falls represent a leading cause of injury among nursing home residents, particularly those with cognitive impairment who may lack awareness of their physical limitations. When falls go unreported and uninvestigated, facilities lose critical opportunities to identify contributing factors and implement interventions that could prevent future incidents. Head injuries from falls can result in serious complications including subdural hematomas, which may not manifest symptoms immediately but can be life-threatening if undetected. The failure to conduct neurological monitoring after a head-strike fall creates substantial risk for undetected brain injury.
Improper Wound Care Techniques Observed
Inspectors observed concerning wound care practices when a nursing assistant used rough, reusable washcloths to clean around a stage 3 pressure ulcer on a resident's coccyx area. The resident had experienced a bowel movement, and the assistant was observed placing a reusable washcloth under running water in the bathroom sink, using it to clean the resident, then placing the soiled cloth directly into the linen hamper. The assistant then used another reusable washcloth to clean around the wound site.
When questioned, the nursing assistant acknowledged that washcloths "could be kind of rough" and stated she was unaware of where to find disposable personal cleansing wipes within the facility. She recognized that rough washcloths could potentially cause redness or skin tears to residents, particularly around wound areas, and that this could cause resident agitation.
A treatment nurse explained to inspectors that treatment staff responsible for wound care use gauze and normal saline solution, and that nursing assistants should not use reusable washcloths to clean around wounds. The nurse stated that washcloths are rougher than appropriate materials and could irritate the resident's skin, especially around wound areas, potentially causing bleeding and pain.
Pressure ulcers develop when sustained pressure restricts blood flow to skin and underlying tissue. Stage 3 ulcers involve full-thickness skin loss extending into subcutaneous tissue, creating deep, crater-like wounds. Proper wound care requires maintaining a clean wound environment to promote healing and prevent infection. Using rough materials around wound sites can damage fragile healing tissue and introduce bacteria from other body areas into the wound bed.
The facility's central supply staff informed inspectors that the facility had recently depleted much of its supply of disposable cleansing wipes during a water shutoff incident and currently had only two 12-pack boxes remaining. The staff member expressed concern that if another water shutoff occurred, the facility would not have adequate supplies to accommodate all residents.
According to the facility's own wound care policy, dated March 2023, the procedure for wound care specifically lists "disposable cloths" among necessary equipment and supplies. The policy instructs staff to remove soiled disposable cloths and discard them into designated containers, not to place them in linen hampers for reuse.
For residents with pressure ulcers in the sacral or coccyx region, proper incontinence care becomes even more critical. Bowel movements introduce bacteria that can easily contaminate wounds in these areas. The facility's prevention of pressure injuries policy specifically states that staff should clean promptly after incontinence episodes, use barrier products to protect skin from moisture, and avoid rubbing or causing friction on skin at risk for pressure injuries.
Infection Control Failures Documented
The facility demonstrated inadequate infection control practices in handling contaminated linens from residents with highly resistant bacterial infections. Six residents in the facility carried drug-resistant organisms including carbapenem-resistant Enterobacterales (CRE), Candida auris, extended-spectrum beta-lactamase (ESBL) producing bacteria, and carbapenem-resistant Pseudomonas aeruginosa—all organisms designated by the Centers for Disease Control and Prevention as urgent or serious antibiotic resistance threats.
Residents colonized or infected with these organisms require contact isolation precautions, meaning healthcare workers must wear gowns and gloves when providing care and must take special precautions to prevent transmission to other residents or environmental surfaces.
During interviews, a nursing assistant explained that dirty linens from isolation rooms were placed in single black bags—the same color bags used for all other dirty linens—and staff would verbally inform laundry personnel that the bag came from an isolation room. The assistant stated that isolation linens were not double-bagged and bags were not labeled with any indication of isolation status or type of organism present.
The laundry worker told inspectors that isolation linens should be double-bagged and labeled with the resident's room and bed number, then placed in a designated isolation cart in the garage. However, the worker noted that both regular dirty linens and isolation linens were placed in identical black bags, making it impossible to distinguish isolation linens if they were not double-bagged as required.
When questioned about the purpose of separating isolation linens from regular dirty linens, the laundry worker correctly identified that the practice prevents spread of infection and protects residents from getting sick. However, the worker acknowledged that without proper double-bagging and labeling, there was no way to identify which bags contained isolation linens.
The Director of Nursing provided a contradictory explanation, stating that all dirty linens were placed in hampers regardless of isolation status because "everything was considered dirty" and the washing process should eliminate all microorganisms through water temperature. This statement reflects a fundamental misunderstanding of infection control principles and proper handling of contaminated materials.
Drug-resistant organisms like CRE and Candida auris can survive on environmental surfaces and fabrics for extended periods. While proper laundering does kill most organisms, the risk of transmission occurs during the handling, transport, and sorting of contaminated linens before washing occurs. Laundry workers who unknowingly handle linens contaminated with highly resistant organisms without appropriate precautions face occupational exposure risk. Additionally, if contaminated linens are transported or stored improperly, organisms can spread to environmental surfaces, clean linens, or other residents' belongings.
The facility's own standard precautions policy, revised April 2023, specifically states that linen soiled with blood, body fluids, secretions, and excretions must be handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other residents and environments. The facility's laundry and bedding policy states that soiled laundry shall be handled, transported, and processed according to best practices for infection prevention and control.
Additional Issues Identified
Beyond these major violations, inspectors documented that the facility failed to develop and implement comprehensive care plans addressing identified resident needs. For one resident whose family member complained about excessive television noise and curtain manipulation creating conflict between roommates, the facility conducted an investigation and recommended that nursing supervisors conduct rounds to ensure safety measures and appropriate noise levels. However, this intervention was never incorporated into a care plan, and nursing supervisors were unaware they should be monitoring the situation.
Care plans serve as roadmaps for individualized resident care, translating assessments and physician orders into specific nursing interventions. When care plans are not updated to reflect identified problems or recommended interventions, staff lack guidance about what monitoring or actions are needed, creating gaps in care delivery.
The inspection findings reveal systemic problems with the facility's quality assurance processes. The unreported fall indicates breakdown in basic incident reporting and communication systems. The improper wound care practices suggest inadequate staff training and supervision. The infection control failures demonstrate lack of consistent policy implementation and oversight. Collectively, these deficiencies point to insufficient management systems to ensure that established policies translate into actual practice at the bedside.
Nursing homes are required by federal regulation to maintain comprehensive assessment and care planning systems, provide necessary care and services to help each resident achieve or maintain the highest practicable level of functioning, and maintain an infection prevention and control program designed to provide a safe environment. The deficiencies identified at Whittier Pacific Care Center represented failures across all these fundamental requirements, placing residents at risk for preventable complications including injury from falls, delayed wound healing, and healthcare-associated infections with drug-resistant organisms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whittier Pacific Care Center from 2024-08-16 including all violations, facility responses, and corrective action plans.
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