Whittier Pacific Care: Undocumented Falls, Wound Care - CA
The August 1 incident at Whittier Pacific Care Center involved Resident 1, who had fallen before and was known to have poor safety awareness and an unsteady gait. Federal inspectors found no documentation of the fall in the resident's medical chart when they arrived August 15.
"I was not aware of Resident 1's latest fall on 8/1/2024 and only became aware of it today," the Assistant Director of Nursing told inspectors on August 15.
The nursing assistant, identified as CNA 1, described moving a wheelchair that was blocking the path to the resident's bed. "I told Resident 1 to please wait for me while I move the wheelchair," she said. "I turned my back on the resident to move the wheelchair three to four feet further into the room when I suddenly heard a noise hit the ground and Resident 1 let out a soft yell."
When CNA 1 turned around, she found the resident sitting upright on the floor next to the shower chair.
Resident 1, who has muscle weakness, osteoarthritis, and dementia, told inspectors she had been reaching for clothes in her closet when she stood up from the shower chair and slipped. "She was not wearing shoes," according to the inspection report.
The resident's care plan, last revised in August 2023, identified her as at risk for falls due to difficulty walking, lack of coordination, muscle weakness, psychiatric medications, and poor safety awareness. She had previously fallen on May 15, 2023, when she stood up to reach for something in her closet despite being told not to stand.
But after the August 1 fall, none of the facility's required protocols were followed.
"There was no documented evidence Resident 1's fall was documented in the resident's clinical record, it was not investigated for the root cause, there was no change of condition assessment, no SBAR Communication Form, no care plan developed, no skin assessment, no 72 hour neurological checks, and no interdisciplinary team meeting was done after the resident fall," the Assistant Director of Nursing acknowledged.
The facility's own policy requires documenting vital signs, recent injury, neurological status, pain levels, precipitating factors, and details of how the fall occurred. Staff must also evaluate when and where falls happen and observe the events surrounding them.
None of this happened.
The Assistant Director of Nursing said the care plan should have been revised "to determine what happened and to prevent a fall from happening again."
Meanwhile, infection control violations affected six residents with dangerous antibiotic-resistant bacteria. Staff were supposed to double-bag contaminated linens from isolation rooms and label them, but a nursing assistant told inspectors isolation linens were only placed in single bags with no labels.
"If the dirty linen bags were not labeled and the Laundry did not know what isolation was in each bag, there could be cross contamination and could cause a spread of infection," CNA 1 said.
The laundry worker confirmed the problem: "If the isolation linen was not double bagged, the LP would not know the isolation linen was actually isolation linen."
Six residents were on contact isolation for carbapenem-resistant bacteria, including CRE, CRAB, and Candida auris. These organisms cause infections that are difficult to treat and spread easily in healthcare facilities.
Resident 3 carried both CRE and Candida auris. Resident 4 had extended spectrum beta lactamase resistance and candidiasis. Resident 5 was isolated for CRE and CRAB. The violations put all residents at risk for serious illness.
Wound care practices also violated facility policies. During one observation, CNA 2 used rough, reusable washcloths to clean around a stage 3 pressure ulcer on Resident 2's coccyx after the resident had a bowel movement.
"The wash cloth could be kind of rough because of washcloths were re-usable," CNA 2 said. She didn't know where to find disposable cleansing wipes in the facility.
The treatment nurse explained why this mattered: "CNAs should not have used a reusable wash cloth to clean around the wound because the reusable wash cloth was rougher than what the TLVN would use, and the reusable wash cloth could irritate the resident's skin especially around the wound area."
If the resident's skin became irritated, "the irritation could cause bleeding and could be painful for the resident."
The facility's central supply department had only two boxes of disposable wipes remaining after using three boxes during a recent water shutoff. The supply staff said if water was shut off again, "the facility would not have enough wipes to accommodate all the residents in the building."
Both residents with pressure ulcers required specialized wound care. Resident 1 had a stage 4 pressure ulcer extending through fascia into muscle, tendon, or bone. Resident 2's stage 3 wound was a deep, cavity-like opening where skin had lost all thickness including subcutaneous tissue.
The facility's wound care policy specifically requires disposable cloths and states that "all clean items were on a clean field." But staff were observed using reusable washcloths that went directly into the linen hamper after cleaning around open wounds.
A separate violation involved family conflict in a shared room. Two family members disagreed about television volume and privacy curtains, leading to a formal grievance on July 22. One family member complained the other allowed the resident to play with curtains "by pulling it from one side of the room to another" and kept the TV volume too loud.
The Social Services Director and Assistant Director of Nursing spoke with the family member on July 25 about safety concerns. They recommended nursing supervisors conduct rounds to ensure safety measures and appropriate noise levels.
But no care plan was developed to address the resident's behavior or implement the recommended monitoring.
"The nursing staff was aware of the grievance and situation between FM 1 and FM 2 which should had been addressed in the resident's care plan to monitor Resident 5's behavior and assess the noise level in the room to prevent conflict between two family members," the Administrator said.
When inspectors interviewed the registered nurse and licensed vocational nurse responsible for the residents, both said they were unaware of any monitoring requirements for television volume or privacy curtains.
The violations demonstrate systemic failures in basic care protocols. A resident fell and suffered potential injury, but staff failed to document, investigate, or prevent future falls. Residents with dangerous infections had their contaminated linens mixed with regular laundry. Pressure ulcers were cleaned with rough washcloths that could cause additional skin damage.
Each violation represented a missed opportunity to protect vulnerable residents who depend entirely on facility staff for their safety and medical care.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WHITTIER PACIFIC CARE CENTER in WHITTIER, CA was cited for violations during a health inspection on August 16, 2024.
Federal inspectors found no documentation of the fall in the resident's medical chart when they arrived August 15.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.