Resident 198 had been admitted to Whittier Pacific Care Center on January 16 with spinal stenosis and coordination problems. His care plan listed him as high fall risk due to intermittent confusion, poor safety awareness, history of falls, unsteady gait, and poor balance.
Federal inspectors witnessed the fall during their January 31 visit to the facility on South Pickering Avenue.
Housekeeper 1 told inspectors she had mopped around the resident's bed and in front of his door around 7:20 AM, then placed the wet floor sign in front of the doorway "to alert anyone that was going to enter the room the floor was wet."
Licensed Vocational Nurse 3 was getting ready to pass medications on the other side of the nursing station when she heard that Resident 198 had fallen. She told inspectors the resident was on frequent monitoring due to his fall history but she couldn't be everywhere at once.
"Wet floor sign should not have been left in front of Resident 198's room doorway as it was considered a hazard for Resident 198 who is high fall risk and has unsteady gait and balance," the Director of Nursing told inspectors.
The facility's own policy states that staff should "make the environment as free from accident hazards as possible."
But environmental hazards were just one problem inspectors documented during their three-day visit to the 180-bed facility.
Catheter Care Failures
Resident 82 had been readmitted in November with respiratory failure, a stage 4 pressure ulcer, and sepsis. She required a catheter for wound care management, but nurses weren't following basic safety protocols.
On January 28, inspectors observed sediment and cloudiness in her catheter drainage tubing and bag. The next day, they found the catheter wasn't strapped to her leg and had more sediment in the tubing.
Treatment Nurse 1 examined the catheter with inspectors and admitted it "should not look like that." She said the sediment could indicate a urinary tract infection and that the unstrapped catheter could be dislodged, causing trauma to the catheter site.
The nurse said she couldn't flush the catheter with saline because sediment might be clogging it. She also told inspectors no change-of-condition report had been filed, meaning "the physician was not aware of the sediment."
Records showed nurses hadn't documented the color and consistency of Resident 82's urine from January 1 through January 30, despite physician orders to monitor those characteristics.
Medication Errors
During a medication pass observation on January 30, Licensed Vocational Nurse 1 administered nine medications to Resident 86 through his feeding tube without flushing water between each medication.
The resident received aspirin, cranberry tablets, pantoprazole, glycopyrrolate, amino acids, methocarbamol, multivitamins, and vitamin C consecutively through the tube without proper flushing.
When questioned, the nurse admitted she "should have flushed before with 5-10 ml of water in between medications" and acknowledged "there was a possibility of drug reaction that may deactivate the medications."
The facility's own policy requires flushing with 15 mL of water between each medication to prevent drug interactions and ensure proper delivery.
This created a 33.3 percent medication error rate for the observed pass.
Staffing Shortages Disrupt Care
The facility failed to provide adequate staffing for specialized rehabilitation services, leaving residents without physician-ordered exercises designed to prevent mobility decline.
Records showed that on multiple days throughout 2024, Restorative Nursing Assistants were reassigned to perform basic nursing assistant duties due to staffing shortages, or no RNA staff were scheduled at all.
RNA 1 told inspectors that when the facility was short-staffed, "RNAs would be pulled to perform the CNA's assignments instead of RNA assignment." If this happened and no replacement was found, "the residents on that RNA's assignment list would not receive their RNA program on that day."
The Director of Staff Development confirmed that residents missed their physician-ordered rehabilitation exercises on August 1, August 6, October 4, January 3, and multiple other dates due to inadequate staffing.
"It was important to ensure enough RNAs available to provide the RNA program to the residents as the physician's order to prevent the development of contracture and promote ROM," the staff development director said.
Missing Assessments
Resident 14, who had lived at the facility since 2010 and had hemiplegia, hadn't received required annual joint mobility assessments. The last occupational therapy screening was completed in 2022, with no subsequent evaluations documented.
The Director of Rehabilitation acknowledged missing the 2024 assessments entirely, calling the screenings "essential for monitoring joint function and maintaining residents' physical capabilities."
Improper Use of Bed Rails
Resident 298 was placed on bilateral upper bed rails immediately upon admission without attempting less restrictive alternatives first, as required by federal regulations.
The facility's own policy lists alternatives including "roll guards, foam bumpers, lowering the bed, or use of concave mattresses" that should be tried before using bed rails.
Licensed Vocational Nurse 1 told inspectors that "most residents get placed on side rails upon admission" to her unit, contradicting federal requirements to use the least restrictive measures first.
Garbage Management Problems
Inspectors found two outdoor refuse containers with lids propped open by red sticks, leaving garbage exposed and overflowing.
The Maintenance Supervisor explained that some staff couldn't reach the high container openings and used sticks to prop them open, but "forgot to remove the red stick and close the lid."
He acknowledged the containers "should be closed at all times to prevent infestation of insects and pests, and to prevent illness to the residents, staff and visitors."
Inadequate Staff Training
One Licensed Vocational Nurse hadn't completed required annual competency assessments since 2023, and one Certified Nursing Assistant hadn't been evaluated since 2023, despite facility policies requiring annual competency testing.
The Director of Nursing couldn't explain why the assessments were missed.
Arbitration Agreement Issues
Family Member 1, who signed legal documents as Resident 198's responsible party, told inspectors she "did not know what an arbitration agreement was" and that admission staff "just handed me papers to sign" without explanation.
The Admissions Coordinator said the arbitration document "was self-explanatory" and that she "was not allowed to answer" questions about it.
The Administrator acknowledged that the arbitration agreement "should have been read aloud to Resident 198's responsible party" to ensure informed consent.
The facility's Quality Assessment and Assurance committee had previously been cited for staffing deficiencies in August 2024 but failed to maintain effective oversight to prevent the same problems from recurring during the January inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whittier Pacific Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.