Whittier Hills Health Care Ctr

F-F711

Findings:

During a review of Resident 301's Admission Record, indicated Resident 301 was admitted to the facility on [DATE REDACTED] with diagnosis that included hemiplegia (a condition that causes weakness or loss of the ability to move on one side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to

the area) affecting left non-dominant side, hyperparathyroidism, hyperlipidemia, and Alzheimer's disease (a brain disorder that slowly damages memory and thinking skills).

During a review of Resident 301's GACH 1's Admission History and Physical, dated 12/10/2024, indicated Resident 301 had a past medical history that included type 2 DM.

During a review of Resident 301's Admission Report Check List (a communication form where the facility's Registered Nurse (RN) receives information from GACH 1's RN regarding a resident that would be admitted to the facility, undated, indicated Resident 301 had a history of DM. The form did not have a prefilled area with questions to remind the RNs to ask for the results of the last vital signs including blood sugar check and if insulin was given.

During a review of Resident 301's Nursing Progress Notes, dated 1/8/2025, indicated per GACH 1's record,

The note indicated, Resident 301's blood sugar check was around 151-154 milligrams (mg, unit of weight) per deciliter (dL, unit of volume) (a normal blood sugar level is between 70 and 100 mg/dL) while she was in GACH 1. The note indicated, Resident 301's blood sugar was checked, and the result was at 118 mg/dL.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 During an interview on 1/8/2025 at 9:40 AM with RN 1, RN 1 stated when admitting a resident to the facility,

the RN would receive report from the hospital nurse and complete a report form. RN 1 stated, when the Level of Harm - Minimal harm or resident arrived, the admitting RN would review the hospital record chart including H&P, diagnosis, potential for actual harm medications, and report to the doctor for medical history, medications, and orders. RN 1 stated, based on Resident 301's medical history from GACH 1, Resident 301 had a history of type 2 DM. RN 1 stated, she did Residents Affected - Some not see any order for blood sugar monitoring or any physician progress notes that indicating blood sugar monitoring and treatment were not needed. RN 1 stated, most hospitals sent their patients to the facility with H&P, lab works, Medication Administration Record (MAR) and discharge summary with continue/discontinue medications. RN 1 stated, Resident 301's GACH 1 did not include the resident's MAR and orders during the hospital stay.

During the same interview with RN 1, RN 1 stated, there was no written procedure guides or check list of the hospital records that they need to make sure to review during the admission process. RN 1 stated, they had

an Admission Report Check List form where they filled in with the information reported by the hospital RN prior to the resident's transfer from the hospital to their facility. RN 1 stated, the admission check list form did not include a section to remind the RN to ask for the last vital signs, blood sugar check, or if insulin (medication for high blood sugar levels) was given during the hospital stay.

During an interview on 1/9/2025 at 4:30 PM with the Director of Nurses (DON), the DON stated, the facility did not have a policy and procedure guide for the RNs to follow when admitting a resident to the facility. The DON stated, they did not have a list of hospital records that they expected the RN to review upon resident's admission. The DON stated, she trusted her RNs to know what hospital records to review and to request when some records were not sent with the resident.

During a review of the facility's policy and procedures titled, Quality Assurance and Performance Improvement, revised January 2022, indicated the facility will establish and implement a Quality Assessment and Assurance Committee, develop a written Quality Assurance and Performance Improvement Plan, which will be used to continually assess the facility's performance using a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality. QAPI Plan Components will include the design and scope to include clinical care, address all systems of care and management practices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42854 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary Residents Affected - Some environment to help prevent infection transmission (when a disease-causing microorganism (pathogen) moves from an infected person or animal to a susceptible host) spread to residents, staff members, visitors

in accordance with the facility's policy and procedure on infection control by failing to:

1a. Ensure a contact isolation precaution (containing one in an area prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident's environment) signage was placed at entrance of Resident 204's room.

1b. Ensure Resident 204's family member (Family) 1 wore personal protective equipment (PPE) that included an isolation gown (gown used to protect clothing from contaminants or contacting disease causing organism) and gloves while in the room of Resident 204, who was under contact isolation precautions.

2. Ensure Resident 3's foley catheter bag did not touch the floor.

These deficient practices had the potential to increase the spread of infection to other residents, staff, and visitors in the facility.

Findings:

1. During a review of Resident 204's Admission record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included pneumonia (infection in the lungs caused by bacteria, viruses, or fungi), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe) with exacerbation (worsening of a disease or an increase in its symptoms), and acute respiratory failure (a condition where one does not have enough oxygen in the tissues of the body (hypoxia) or when there is too much carbon dioxide in the blood (hypercapnia) with hypoxia.

During a review of Resident 204's History and Physical (H&P), dated 12/20/2024, indicated the resident had capacity to understand and make decisions.

During a review of Resident 204's Order Summary Report dated 1/9/2025, indicated a physician order for:

a. Valacyclovir hydrochloride (medication used to treat herpes [virus cause contagious sores most often around the mouth or on the genitals] virus infection, including shingles [viral infection that causes a painful rash], cold sores, and genital herpes) Oral Tablet give 1000 milligrams (mg, unit of measurement) by mouth every 8 hours for Shingles for 7 days.

b. Contact Isolation due to Shingles (a viral infection that causes a painful rash with blisters).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation in the hallway near Resident 204's room with the Infection Prevention Nurse (IPN) on 1/9/2025 at 1:10 PM, no contact isolation precaution signage was observed at entrance of Resident 204's Level of Harm - Minimal harm or room. Family 1 was observed in Resident 204's room without wearing an isolation gown. potential for actual harm

During an interview with Family 1 on 1/9/2025 at 1:12 PM, Family 1 stated he did not see the isolation cart Residents Affected - Some with gowns. Family 1 stated he wore a surgical mask and gloves as a precaution, but he was not aware that

he had to wear an isolation gown. IPN informed Family 1 that he had to wear an isolation gown to protect himself not to infected by 204.

During an interview with the IPN on 1/9/2025 at 1:17 PM, IPN stated it was the responsibility of herself and

the nurses to make sure there was proper signage prior to entering Resident 204's room. IPN stated the Contact isolation precaution signage was important because it prompts the visitor or whoever was entering

the room to ask for assistance and wear the correct personal protective equipment (PPE). IPN stated it was important for visitors and staff to wear the correct PPE so they do not get exposed to the infection.

During an interview with the Director of Nursing (DON) on 1/10/2025 at 11:07 AM, the DON stated visitors should be educated to wear PPE before entering a resident room with contact precautions. The DON stated

the importance of wearing PPE is to prevent infection.

During a review of the facility's policy and procedure (P&P) titled Infection Prevention Control Program (ICPC) and Transmission-Based Precautions (TBP) revised date on 10/2022 indicated all residents who have another infection or condition for which contact isolations is recommended, PPE must be used in any room entry. The P&P indicated the required PPE for contact isolation includes gloves and gown, to don

before room entry, and doff before room exit. The P&P also indicated the facility will implement a system to alert staff, residents, and visitors that a resident is on TBP that includes to post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves).

During a review of the facility's contact precautions signage dated 8/2021 indicated STOP, see nurse before entering room; clean hands-on room entry, wear a gown on room entry, wear gloves on room entry and clean hands when exiting.

42878

2. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated a readmission to the facility on [DATE REDACTED] with diagnoses that included of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), chronic obstructive pulmonary disease ( a diseases that blocks airflow and make it hard to breathe).

During a review of Resident 3's History and Physical (H&P) dated 12/24/2024, the H&P indicated the resident has the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 3's Order Summary Report dated 1/10/2025, indicated a physician order for a right lower quadrant abdomen urostomy (a surgical procedure which creates an opening in the abdomen Level of Harm - Minimal harm or through which urine drains from the body) attached to a drain foley bag (a collection bag that receives urine potential for actual harm drained through a catheter), and change the bag on the 3rd day and as needed if dislodged.

Residents Affected - Some During a concurrent observation and interview on 01/08/2025 at 11:31 AM with Licensed Vocational Nurse (LVN )2 in Resident 3's room, Resident 3's foley bag was observed hanging from Resident 3 ' s bed left side rail touching the floor. LVN 2 stated the Foley bag should never be touching or laying on the floor as the floor is dirty and could contaminate and make Resident 3 sick.

During an interview with the Director of Nursing (DON) on 1/10/2025 at 2:07 PM, the DON stated foley catheter bags should never be touching the floor, it is facility policy to keep off the floor to prevent any cross contamination from the floor to the Resident.

During a review of the facility's policy and procedure (P&P) titled Catheter Drainage Bag dated revised on 05/2007 indicated 8. Position the drainage bag below the level of the resident's bladder and the drainage bag should be kept off the floor.

During a review of the facility's policy and procedure (P&P) titled Catheter Drainage Bag dated revised on 05/2007 indicated to position the drainage bag below the level of the resident's bladder and the drainage bag should be kept off the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Some Based on observation, interview, and record review, the facility failed to:

1. Provide sanitary environment for Resident 122 by ensuring an unknown black back brace (a braced used when moving or lifting residents from sitting to standing) was not found in the resident's room on 1/7/2025.

This deficient practice had a potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) when used by Resident 122 and other facility's residents.

2. Maintain a safe, functional door with locks that latch which leads to the patio area to maintain a safe environment for all residents and staff.

This deficient practice had a potential to put the facility's residents and staffs at risk of injury and harm.

Findings:

1. During a review of Resident 122's Admission Record, indicated Resident 122 was admitted to the facility

on [DATE REDACTED] with diagnosis that generalized epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body, and are sometimes accompanied by loss of consciousness) and epileptic syndromes (a set of signs and symptoms that define a type of epilepsy), lack of coordination, dysphagia (difficult swallowing), and difficulty

in walking.

During a review of Resident 122's History and Physical, dated 10/28/2024, indicated Resident 122 could make needs know but could not make medical decisions.

During a review of Resident 122's Inventory of Resident's Personal Belongings, dated 10/28/2024, indicated Resident 122 did not have a back brace in the belonging list.

During a review of Resident 122's Minimum Data Sets (MDS - a resident assessment tool), dated 10/30/2024, indicated Resident 122's cognition (ability to think, remember, and reason with no difficulty) was severely impaired, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, and personal hygiene.

During an observation on 1/7/2025 at 10:15 AM in Resident 122's room, one black back brace was hanging inside the resident ' s room with no name tag.

During an interview on 1/7/2025 at 10:17 AM with Resident 122 in Resident 122's room, Resident 122 stated, the black back brace was not his belongings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 During a concurrent observation and interview on 1/7/2025 at 11 AM with Certified Nurse Assistant (CNA) 1

in Resident 122's room, one black back brace was hanging on a doorknob inside the resident's room. CNA 1 Level of Harm - Minimal harm or stated the back brace was not one of Resident 122's belongings. CNA 1 stated, she noticed the back brace potential for actual harm had been hanging since 6:30 AM when she started her shift. CNA 1 stated, it could belong to one of the night shift staff because the company had been giving out the back brace to support the staffs that was used when Residents Affected - Some lifting residents.

During an interview on 1/9/2025 at 4:30 PM with the Director of Nurses (DON), the DON stated, the facility's staffs should not leave any of their belongings in any resident's room because the resident could take it and use it. The DON stated, the back brace could have bacteria that could cross contaminate bacteria and was unsanitary.

During an interview on 1/10/2025 at 11 AM with the DON, the DON stated, the Social Service Director found

the back brace in the Resident 122's room and could not verify to whom it belongs to. The DON stated, the back brace could be from the previous resident or from an employee. The DON stated, if the brace belonged to the previous resident, the housekeeper should have cleaned the room thoroughly and not left the brace in

the room.

During a review of the facility's policy and procedure (P&P) titled, Housekeeping Policy & Procedure, undated, indicated terminal cleaning of a resident room when resident is discharged included nursing will remove all linen and resident personal care items.

During a review of the facility's P&P titled, Infection Prevention and Control Program, revised 10/2022, indicated facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection.

42854

2. During an observation of the designated smoking area located in the facility's outdoor patio area on 1/6/2025 at 9 AM, observed signage that indicated When doing smoke breaks, kindly close the door. Leave it close until smoke break is over and make sure patio door stays closed. Thank you. Observed door open, and not entirely latched to keep door closed. The hallway where patio door was located smelled like cigarette smoke from residents' designated smoking area.

During an observation of the designated smoking area from the resident hallway where patio door was located on 1/7/2025 at 1:10 PM, observed door still open and not entirely latched to keep door closed. Hallway still smelled like cigarette smoke from residents smoking in the designated smoking area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 During a concurrent observation and interview in the designated smoking area on 1/7/2025 at 1:15 PM, activities assistant (AA) 2 was observed supervising 2 residents for smoke break. AA 2 stated she was Level of Harm - Minimal harm or unable to close the door completely during yesterday's smoke break as well as this morning's smoke break potential for actual harm at 11 AM. AA 2 stated she tried to close the door best she could yesterday and this morning, but the door would not latch to close completely. AA 2 stated she did not report to maintenance or any staff that the door Residents Affected - Some was not closing all the way. AA 2 stated she should have told someone so that it could be fixed. AA 2 stated usually when something is not working or broken, she would report to the maintenance staff or document in

the Maintenance Repair Request Log which was located in the nursing station. AA 2 stated it was important for the door to be completely closed to ensure the cigarette smoke will not go into the facility.

During a concurrent interview and observation of the patio door from resident hallway on 1/7/2025 at 1:46 PM, the Maintenance Supervisor (MS) confirmed that the door going to the designated smoking area was not able to latching and keep door closed. MS stated he was unaware of this door not working until now. MS stated when he arrives at the facility each morning, he conducts maintenance room rounds and checks the Maintenance Repair Request Logs in nursing stations. MS stated he would fix what staff tell him. MS stated if

he observes that something was not working, he will fix it. MS stated checking the facility doors was not part of maintenance rounds. MS stated he did not have a log for maintenance rounds. MS stated at the moment

the patio door does not lock from the inside or the outside. MS could not recall how long the patio door was not locked.

During a tour of designated smoking area and maintenance area on 1/7/2025 at 1:50 PM, observed a fence separated the designated smoking area and maintenance area. Observed a latch on the fence door has no lock. In the Maintenance area was a parking lot for maintenance staff and a driveway that lead to facility's main parking lot. No gates observed, driveway open and easily accessible to the public. MS stated the fence that separates the designated smoking area and maintenance area was never locked. MS stated in the event

the fire department wants to get into the facility, they do not lock the fence.

During a concurrent interview and record review of the facility's Maintenance Repair Request Logs for 1/2025 from Nursing Stations 1 and 2 on 1/7/2025 at 1:24 PM, MS confirmed there was no request to fix patio door. MS stated he will fix the door now. MS stated he did not have any other log for routine inspections, he would fix things based on his visual observations and what was reported in the Maintenance Repair Request Log, nothing else.

During an interview with the Administrator (ADM) on 1/7/2024 at 4:20 PM, the ADM stated the Registered Nurse Supervisor (RNS) and receptionist locks the facility doors after visiting hours which was 8 PM. ADM stated he trusts his staff and knows that the doors are always locked. The ADM stated they could use a log to make sure the doors are functional and locked, but don't have log currently. The ADM stated he will follow up with MS regarding the patio door and will have a correction tomorrow.

During a concurrent interview and observation of patio door with MS and ADM on 1/8/2025 at 9 AM, observed patio door function and able to latch and close completely. MS stated the latch was fixed yesterday and the door is now able to be kept closed. MS stated the door closer located at the top of the door was also fixed to be able to lock the door from outside so that no one can enter facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 During a concurrent interview and observation of fence door with MS and ADM on 1/8/2025 at 9:03 AM, observed a black pad lock on latch. MS stated there are only 2 people has key access to open fence door Level of Harm - Minimal harm or pad lock. MS stated only himself and his assistant have key and will lock the fence door pad lock after their potential for actual harm shift. ADM stated the fence door will remain locked for residents' safety.

Residents Affected - Some During an interview with the Director of Nursing (DON) on 1/10/2025 at 11:08 AM, the DON stated the doors

in the facility should remained closed and locked to ensure no one comes in the facility. The DON stated the function of the patio door should have been reported and that anyone could have reported it was broken.

During a review of the facility's policy & procedure (P&P) titled Safety, Resident revised on 9/2019 indicated

the facility would create a safe environment for the resident. The P&P indicated to report all faulty equipment immediately and do not use.

During a review of the facility's P&P titled Physical Environment revised on 5/2022 indicated the facility would establish procedures for routine and non-routine care equipment and to ensure that it remains in good working order for resident and staff safety. The P&P indicated routine inspections, and maintenance will be recorded in the Preventive Maintenance Log.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0926 Have policies on smoking.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42878 potential for actual harm Based on observation, interview, and record review the facility failed to implement their smoking policy and Residents Affected - Few procedure for one of three sampled residents (Resident 97) by failing to provide a smoke free environment as indicated in the facilities policy.

This deficient practice had the potential to place Resident 97 at risk associated with inhaling secondhand smoke that can potentially lead to diseases such as lung cancer, stroke, heart disease and death.

Findings:

During a review of Resident 97's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated admission to the facility on [DATE REDACTED] with diagnoses that included stress fracture (a small crack in a bine caused by repetitive force or over use) of the left femur (left thigh bone), morbid obesity due to excess calories (a condition of having to much body fat) .

During a review of Resident 97's History and Physical (H&P) dated 11/23/2024, the H&P indicated the resident has the capacity to understand and make decisions.

During a review of Resident 97's Minimum Data Set (MDS - a resident assessment tool), dated 10/22/2024, indicated the resident cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact.

During a review of facility provided document titled Grievance Resolution Form dated 11/20/2024 timed at 2:15 PM, indicated a grievance received by Resident 97 to Activities Assistant 1 (AA1). The grievance indicated Resident 97 reported smelling smoke from resident smoking outside at smoking patio. Furthermore, the form indicated steps taken to investigate grievance included: SSA assistant offered room change, sign put in place to close door when smoking.

During an interview on 1/06/2025 at 9:35 AM with Resident 97, Resident 97 stated she had filed a grievance with the facility regarding the strong smell cigarette of smoke that she can smell all day, but it gets especially worst during smoke break. Resident 97 stated the facility offered to switch her room, but she has had many rooms changes in the past and did not want to move again. Resident 97 stated the SSA 1 had told her she would put a sign by the door to keep the door closed and would tell all the staff but despite of that the smell continued to come into her room everyday just as strong if not even stronger.

During an observation on 1/06/2025 at 1:15 PM of patio exit doorway directly across Resident 97's room, there was a sign observed next to the exit doorway indicating When doing smoke breaks, kindly close the door (For Resident 97 ' s room). Leave it closed until smoke break is over and make sure patio door stays closed. The door was observed cracked open while Residents were observed outside smoking during their smoke break.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0926 During an observation and concurrent interview on 1/07/2025 at 1:16 PM with Certified Nursing Assistant (CNA)3, CNA 3 stated she could smell smoke in the hallway in front of Resident 97's room. CNA 3 stated the Level of Harm - Minimal harm or cigarette smoke smell was coming in from the outside because there were Residents outside in the patio potential for actual harm currently on smoke break and the door was cracked opened.

Residents Affected - Few During a concurrent observation and interview on 1/07/2024 at 1:20 PM with Maintenance Assistant (MA)2 of Patio door across resident 97's room that leads to smoking Patio. MA2 stated door was opened because the latch that keeps the door closed was broken preventing the door from closing. MA 2 stated he was not aware

the door latch was broken and would not close and did not know how long it had been broken as it was not reported to the maintenance department.

During an interview on 1/10/2025 at 10:51 AM with Director of Nursing (DON), DON stated some of the complications that can be caused by secondhand smoke could be cancer or other health conditions for some people. DON stated the facility had implemented steps such as posting the signage on the door across from Resident 97's door to remind everyone to keep the door closed during smoke breaks to prevent cigarette smoke from entering the facility and going into Resident 97's room but was not aware the door latch was not working until 1/7/2025.

During a review of the facility's policy and procedure (P&P) titled Smoking Policy dated with a revised date of 12/2016 indicated It is the facility policy to provide to it's residents a smoke free environment .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 47 055430

F-F867 Residents Affected - Few Based on interview, and record review, the facility failed to provide care and services to one of - sampled residents (Resident 301) with diagnosis of Diabetes Mellitus (DM, condition that results in too much sugar circulating in the blood) by failing to:

1. Ensure Resident 301 ' s blood sugar was monitored for high or low blood sugar level.

2. Ensure Admitting Registered Nurse (RN) clarified with Resident 301 ' s physician for blood sugar monitoring and treatment.

3. Ensure Nurse Practitioner (NP) 1 thoroughly reviewed Resident 301 ' s General Acute Hospital (GACH) 1 ' s discharge packet when NP 1 took over the care of Resident 301 to clarify Resident 301 ' s history of type 2 Diabetes Mellitus as documented in Resident 301 ' s GACH 1 ' s H&P and justified the need to continue or discontinue blood sugar monitoring and treatment.

These deficient practices had a potential to result in Resident 301 ' s to developed uncontrolled blood sugar level that could lead to complication such as ketoacidosis (metabolic condition that occurs when the body produces too many ketone bodies, which can lead to dangerous levels of acid in the blood) coma, hospitalization or death.

Findings:

During a review of Resident 301 ' s Admission Record, indicated Resident 301 was admitted to the facility on [DATE REDACTED] with diagnosis that included hemiplegia (a condition that causes weakness or loss of the ability to move on one side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to

the area) affecting left non-dominant side, hyperparathyroidism, hyperlipidemia, and Alzheimer ' s disease (a brain disorder that slowly damages memory and thinking skills). The admission record did not indicate that Resident 310 had a diagnosis of DM.

During a review of Resident 301 ' s GACH 1 Admission History and Physical, dated 12/10/2024, indicated Resident 301 had a past medical history that included type 2 DM.

During a review of Resident 301 ' s Medication Administration Record (MAR), from GACH 1, indicated Resident 301 was given insulin Lispro (treatment medication for high blood sugar levels) on 12/10/2024 at 9:20 PM; 12/11/2024 at 5:57 PM and 8:38 PM; 12/12/2024 at 5:58 PM and 10:20 PM; 12/13/2024 at 9:02 AM, 12:08 PM, and 5:45 PM; 12/15/2024 at 9:59 AM; 12/16/2024 at 12:24 PM and 5:24 PM; 12/17/2024 at 1:49 PM; 12/18/2024 at 8:36 AM, 12:15 PM, 5:04 PM and 9:21 PM; 12/19/2024 at 10:44 AM, 1:39 PM; 12/20/2024 at 6:24 PM; 12/21/2024 at 6:11 PM; and 12/28/2024 at 6:32 AM.

During a review of Resident 301 ' s Admission Report Check List (ARCL, a communication form completed by the facility ' s Registered Nurse (RN) when receiving information from the GACH regarding a resident prior to admission to the facility), undated, indicated Resident 301 had a history of DM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During a review of Resident 301 ' s Admission Notes, dated 1/2/2025, indicated Resident 301 was admitted

on [DATE REDACTED] at 5:45 PM with medical health history that included DM. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 301 ' s Initial Visit NP (Nurse Practitioner) Progress Note, dated 1/3/2025, documented by NP 2, there was no indication that Resident 301 had a history of type 2 DM. The note did not Residents Affected - Few indicate to monitor Resident 301 ' s blood sugar level or to monitor for sign and symptoms of high blood sugar level (such as restlessness, feeling tired, excessive thirst) or low blood sugar level (such as weakness, dizziness or hungry).

During a review of Resident 301 ' s Physician Admission Progress Note, dated 1/6/2025, indicated no documentation that Resident 301 had a history of DM, and there was physician note that indicate to monitor Resident 301 ' s blood sugar level or monitor for high or low blood sugar level.

During a review of Resident 301 ' s care plans, indicated no care plan was developed to address interventions to address the resident ' s diagnosis of DM.

During an observation on 1/7/2025 at 9:53 AM in Resident 301 ' s room, Resident 301 was lying in bed, connected with a tube feeding. Resident 301 ' s eyes were staring at the ceiling and Resident 301 was not able to answer any questions.

During a review of Resident 301 ' s Nursing Progress Notes, dated 1/8/2025, documented by RN 1 at 10:14 AM, indicated per GACH 1 ' s record, Resident 301 was noted with history of type 2 DM and there was no medication ordered by the physician to treat DM, and RN 1 received an order from Nurse Practitioner (NP) 1 to monitor the resident ' s blood sugar. RN 1 documented she was informed by Resident 301 ' s family member (FAM)1 that Resident 301 was not diagnosed with DM prior to hospitalization to GACH 1, and the resident ' s blood sugar checked in the GACH with the result of around 151-154 milligrams (mg, unit of weight) per deciliter (dL, unit of volume) (a normal blood sugar level is between 70 and 100 mg/dL). The note also indicated, Resident 301 ' s blood sugar was checked, and the result was at 118 mg/dL.

During a concurrent record review and interview on 1/8/2025 at 9:40 AM with RN 1, Resident 301 ' s GACH 1 ' s discharge packet and Resident 301 ' s ARCL form were reviewed. RN 1 stated, RN 3 was the one that received the report from GACH 1 and completed Resident 301 ' s ARCL form prior to admission that indicated Resident 301 had a history of type 2 DM. RN 1 stated, most GACHs sent their patients to the facility with H&P, lab works, Medication Administration Record (MAR) and discharge summary with continue/discontinue medications. RN 1 stated, she could not find Resident 301 ' s GACH 1 ' s physician orders and MAR to review.

During a concurrent record review and interview on 1/8/2025 at 9:55 AM with RN 1, Resident 301 ' s physician orders was reviewed. RN 1 stated, there was no physician order for Resident 301 to be monitored for blood sugar, lab draw or treatment. RN 1 stated, RN 3 should have informed and verified with the doctor for Resident 301 ' s history of DM, especially when Resident 301 was on NPO (nothing by mouth) and on tube feeding. RN 1 stated, if Resident 301 ' s blood sugar monitoring and treatment was not needed, it should have been documented in the physician progress note.

During an interview on 1/8/2025 at 10 AM with RN 1, RN 1 stated, she would notify Resident 301 ' s physician regarding Resident 301 ' s history of DM to obtain orders and would call Resident 301 ' s family member (FAM 1) for a change in the physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During a concurrent record review and interview on 1/8/2025 at 10:35 AM with the MDSN, Resident 301 ' s electronic medical record (EMR) did not have Resident 301 ' s diagnosis available for review since the Level of Harm - Minimal harm or resident was admitted to the facility 6 days ago. The MDSN stated, Resident 301 ' s diagnosis should be potential for actual harm available for review in EMR within 24 hours after admission. The MDSN stated, the LVNs who has been taking care of Resident 301 would not know if Resident 301 had DM if they only review the information via Residents Affected - Few EMR.

During a concurrent record review and interview on 1/8/2025 at 10:45 AM with the MDSN, Resident 301 ' s GACH 1 ' s discharge packet was reviewed. The MDSN stated, based on GACH 1 ' s record, Resident 301 had a history of DM. The MDSN stated, she was not aware of Resident 301 ' s history of DM because she did not have a chance to review Resident 301 ' s GACH 1 ' s discharge packet. The MDSN stated, she created Resident 301 ' s care plan based on the information available via EMR and active physician orders without reviewing Resident 301 ' s discharge packet so she did not create a care plan to address Resident 301 ' s DM.

During an interview on 1/8/2025 at 4:35 PM with Resident 301 ' s NP 1, NP 1 stated, when Resident 301 was admitted to the facility on [DATE REDACTED], NP 1 was on vacation and NP 2 was covering for her. NP 1 stated, she came back and took over on 1/6/2025. NP 1 stated, she did not review Resident 301 ' s GACH 1 ' s discharge packet because NP 2 was supposed to review the documents during initial visit of the resident, the NP 1 stated, NP 2 did not inform her about Resident 301 ' s history of DM. NP 1 stated, FAM 1 informed her that Resident 301 ' s blood sugar was being monitored during hospital stay and insulin was given. NP 1 stated, if she was the NP that admitted Resident 301, she would have ordered blood sugar check, and some lab works to rule out DM and document them in her progress notes.

During an interview on 1/9/2025 at 4:30 PM with the Director of Nurses (DON), the DON stated, the admitting RN should have thoroughly reviewed Resident 301 ' s discharge packet and clarified the orders and diagnosis. The DON stated, it should be documented in the physician progress note if the resident had history of DM and if they decided not to monitor for blood sugar and not to treat it. The DON stated, the facility did not have a policy and procedure guide for the RN to follow when admitting a resident to the facility.

The DON stated, they did not have a list of GACH records that they expected the RN to review upon resident ' s admission. The DON stated, she trusted her RNs to know what GACH records to review and to request when some records were not sent with the resident.

During a review of the facility ' s policy and procedure (P&P) titled, Physician visits, revised June 2019, indicated during the initial visit, the physician shall complete a thorough assessment, develop plan of care and writes or verifies admitting orders for the resident.

During a review of the facility ' s P&P titled, Diabetes Mellitus Resident, Nursing Care of, revised November 2019, indicated the following:

-It is the policy of the facility to assist the resident to establish a balance between diet/exercise and insulin, prevent recurrence of hypoglycemia, and recognize complications commonly associated with diabetes.

-Diabetes Mellitus is defined as chronic hereditary or developmental disorder in which there is relative or absolute lack of insulin effect characterized by disturbed metabolism or glucose, fat, and/or protein.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 -Documentation may include the following: vital signs, pertinent laboratory studies including blood sugar.

Level of Harm - Minimal harm or During a review of the facility ' s P&P titled, Documentation and Charting, revised May 2019, indicated it is potential for actual harm the policy of the facility to provide resident ' s care, treatment, response to care, guidance to the physician in prescribing appropriate medications and treatments; a tool for measuring the quality of care provided to the Residents Affected - Few resident; and assistance in the development of a Plan of Care for each resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50012

Residents Affected - Few Based on interview, observation, and record review, the facility failed to provide a properly place and sized knee immobilizer (a device typically used for injuries that benefit from immobilization but can tolerate brief periods without immobilization to help relief pain and healing) for one (Resident 351) out of three sample residents.

As a result of this failure Resident 351 was at risk for injury, discomfort, and complications, such as impaired mobility and skin breakdown.

Findings:

During a review of Resident 351's Admission Record (Face Sheet), indicated the resident was admitted to

the facility on [DATE REDACTED], with diagnoses including fracture (a break in a bone) of the right patella (kneecap), and history of falling.

During a review of Resident 351's History and Physical (H&P), dated 12/13/2024 indicated, Resident 351 had the mental capacity to make medical decisions.

During a review of Resident 351's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 12/13/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and was dependent from the staff for the activities of daily living.

During an observation on 1/6/2025 at 10 AM, Resident 351 was observed standing in the room without the prescribed knee immobilizer on her knee. The knee immobilizer was positioned at her ankle instead of providing support to her knee. Resident 351 stated, this happens a lot. The brace keeps sliding down, and it doesn't feel like it's helping much.

During a concurrent observation and interview on 1/6/2024 at 10:28 AM, with Resident 351, Resident 351 room was observed sitting in a wheelchair with a knee immobilizer on the right leg. The immobilizer appeared loose, with visible gaps around the resident's knee and thigh. License Vocational Nurse 3 (LVN 3) confirmed during the observation that the immobilizer needed to be adjusted.

During an interview on 1/7/2024 at 10:30 AM with LVN 3, stated the knee immobilizer must be properly positioned to provide stability and support to the knee and it is checked during rounds, LVN 3 stated it may have slipped, depending on the resident's movements. LVN 3 stated that there was no recent report had been made to therapy regarding the immobilizer slipping frequently.

During an interview on 1/9/2024 at 4:35 PM with Physical Therapist (PT 1), stated having to adjust the immobilizer multiple times during therapy sessions to ensure it stayed in place. PT 1 stated, once it ' s properly strapped, it works, but the resident would benefit from a properly sized immobilizer. PT 1 stated that no action had been taken to order a replacement immobilizer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During an interview on 1/9/2024 at 4:35 PM with Director of Nursing (DON), DON stated that a properly fitting knee immobilizer is critical for stabilizing the joint, supporting mobility, and preventing further injury or strain. Level of Harm - Minimal harm or The DON stated, If the immobilizer is not the right size or improperly placed, it cannot provide the intended potential for actual harm support and may lead to discomfort or even harm. It's essential that these issues are addressed promptly. DON stated that was no reports regarding the immobilizer's improper fit that had been communicated to Residents Affected - Few nursing leadership, and no corrective actions were taken to obtain a properly sized replacement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42854

Residents Affected - Some Based on interview and record review, the facility failed to provide interventions for safety and supervision for four of four sampled residents (Residents 29, 56, 89, and 154), who were at risk for elopement (an incident where a resident leaves the facility unsupervised and without staff knowledge).

These deficient practices put Resident 29, 56, 89, and 154 at risk of elopement and potentially lead to serious injury and irreversible harm.

Findings:

a. During a review of Resident 56's Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone, can disrupt heart rate, body temperature and all aspects of metabolism), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities).

During a review of Resident 56's History and Physical (H&P), dated 9/27/2024, indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 56's MDS, dated [DATE REDACTED], indicated the resident had moderately impaired cognitive skills for decision making.

During a review of Resident 56's Elopement/Wandering Evaluation dated 10/2/2024 indicated resident was at high risk for elopement/wandering.

During a concurrent interview and record review of Resident 56's care plans on 1/10/2025 at 9:56 AM, MDS Nurse (MDSN) stated Resident 56's care plan for elopement was created on 1/7/2025. MDSN stated she could not find documented evidence of a care plan or interventions created after Resident 56 was evaluated for elopement/wandering on 10/2/2024. MDSN stated the purpose of the care plan is to take care of the resident and it was the staff's guide to improve or address any issues that the resident has. MDSN stated

she added the care plan for elopement because resident was at high risk for elopement. MDSN stated she was unsure why the care plan was not created after 10/2/2024. MDSN stated if a care plan was not created, no interventions were in place.

During an interview with the Medical Records Director (MRD) on 1/10/2025 at 12:20 PM, MRD stated she could not find elopement/wandering risk documented in Resident 56's Interdisciplinary Team's (IDT) record for care planning.

b. During a review of Resident 154's Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included disorders of urinary system, interstitial pulmonary diseases (group of disorders that cause progressive scarring of lung tissue), and Alzheimer's disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a review of Resident 154's MDS, dated [DATE REDACTED], indicated the resident had moderately impaired cognition. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 154's Elopement/Wandering Evaluation dated 12/25/2024 indicated resident was at high risk for elopement/wandering. Residents Affected - Some

During a concurrent interview and record review of Resident 154's care plans on 1/10/2025 at 10:29 AM, the Social Services Assistant (SSA) stated she met with Resident 154 on 1/7/2025. SSA stated Resident 154 seemed like a flight risk which was someone that can possibly leave the facility. SSA stated she did not

review Resident 154's elopement risk assessment. SSA stated she created the care plan for elopement on 1/7/2025 because Resident 154 verbalized during the conversation she wanted to go home. SSA stated she could not recall if she documented the conversation.

During an interview with the Medical Records Director (MRD) on 1/10/2025 at 12:20 PM, MRD stated she could not find documented evidence of elopement/wandering risk in Resident 154's Interdisciplinary Team (IDT) care planning.

c. During a review of Resident 89's Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin [a protein found in blood cells] to carry oxygen all through the body), difficulty walking, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).

During a review of Resident 89's History and Physical (H&P), dated 9/14/2024, indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 89's MDS, dated [DATE REDACTED], indicated the resident ' s cognition as intact.

During a review of Resident 89's Elopement/Wandering Evaluation dated 9/4/2024 indicated resident was at high risk for elopement/wandering.

During a concurrent interview and record review of Resident 89's care plans on 1/10/2025 at 10:40 AM, the Assistant Director of Nursing (ADON) stated she was reviewing Resident 89's chart and a care plan for elopement on 1/7/2025. The ADON stated she could not find care plan or interventions created and documented after Resident 89 evaluated at high risk of elopement/wandering on 9/4/2024.

During an interview with the Medical Records Director (MRD) on 1/10/2025 at 12:20 PM, MRD stated she could not find elopement/wandering risk documented in Resident 89's Interdisciplinary Team's (IDT) record for care planning.

d. During a review of Resident 29's Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included senile degeneration of brain, encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), and muscle weakness.

During a review of Resident 29's History and Physical (H&P), dated 10/18/2024, indicated the resident did not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a review of Resident 29's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/16/2024, indicated the resident had severely impaired cognition (mental action or process of Level of Harm - Minimal harm or acquiring knowledge and understanding through thought, experience, and the senses). potential for actual harm

During a review of Resident 29's Elopement/Wandering Evaluation dated 11/16/2024 indicated resident was Residents Affected - Some at high risk for elopement/wandering.

During a concurrent interview and record review of Resident 29's care plans on 1/10/2025 at 10:41 AM, the Assistant Director of Nursing (ADON) stated Resident 29's care plan for elopement was created on 1/8/2025.

The ADON stated she could not find documented evidence of a care plan or interventions created after Resident 29 was evaluated for elopement/wandering on 11/16/2024. The ADON stated Resident 29 should have an active elopement care plan because she was at high risk for elopement. The ADON stated the care plan should include interventions to prevent elopement.

During an interview with the Director of Nursing (DON) on 1/10/2025 at 10:54 AM, the DON stated it was important to develop a care plan for residents at risk for elopement so there are interventions to prevent elopement from happening. The DON stated the care plan should have been created as soon as facility knew resident was at risk. The DON stated if there was no care plan there was a possibility the resident could elope. The DON stated she expects the staff to review the elopement assessment and to create a care plan. The DON stated if there were any instances of eloping it should be documented in the progress notes.

During an interview with the Medical Records Director (MRD) on 1/10/2025 at 12:20 PM, MRD stated she could not find elopement/wandering risk documented in Resident 29's Interdisciplinary Team's (IDT) record for care planning.

During a review of the facility's policy and procedure (P&P) titled Elopement/Unsafe Wandering revised on 12/2023 indicated the facility will provide a safe environment as free of accidents as possible for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement.

The P&P indicated residents with high risk factors will be identified as At Risk and will have an individualized care plan developed that includes measurable objectives and time frames. The P&P indicated care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. The P&P also indicated interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or 50012 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one out of three sampled Residents Affected - Few residents (Resident 136) who was identified as at risk for weigh loss, received the prescribed health shake (a nutritional supplement) TID (three times a day) as ordered by the physician.

This failure had the potential to result in further weight loss and dehydration (fluid deficit) that could lead to compromised nutritional status and overall, well being.

Findings:

During a review of Resident 136 ' s Admission Record, the facility admitted Resident 136 on 10/23/2024, with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and difficulty in walking.

During a review of Resident 136 ' s History and Physical (H&P), dated 10/23/2024 indicated, Resident 132 can make needs known but cannot make medical decisions.

During a review of Resident 136's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/25/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for

the activities of daily living.

During a review of Resident 136's Order Summary Report, dated 1/8/2025, the Order Summary Report dated 11/27/2024 indicated to provide Resident 136 with Fortified diet (a diet that includes foods that have had nutrients added to them.) Regular texture, thin liquids consistency, Health Shakes TID with meals.

During a review of Resident 136 ' s care plan, dated 10/23/2024, indicated Resident 136 was at risk for nutritional problem, weight loss/fluctuation (to change or move back and forth), at risk for malnutrition (poor food intake) indicated Resident 136 was at risk for s/s (signs and symptoms) of dehydration r/t (related to) therapeutic diet, s/p (status post) fall secondary to syncope (loss of consciousness), multiple Right Rib fx (fracture- broken bone) no surgery, acute respiratory failure (difficulty breathing), HTN (hypertension), HLD( Hyperlipidemia) , hypothyroid (thyroid gland doesn ' t make or release enough hormone into your bloodstream), Atrial Fibrillation (irregular heartbeat), dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) , anxiety, rhabdomyolysis (condition that causes your muscles to break down), diuretic ( increases flow of urine) medication use. The care plan goal indicated Resident 136 will maintain adequate nutritional status as evidenced by maintaining weight with no s/s of malnutrition through review date. The care plan interventions included to provide Health shakes 4oz TID with meals.

During a concurrent observation and interview on 1/8/2025 at 12:45 PM, with Family member 1 (FM1) of Resident 136, in Resident 136 ' s room, observed meal tray did not include the prescribed health shake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a concurrent observation and interview on 1/8/2025 at 12:45 PM, Family Member 1 (FM1) of Resident 136 was present in Resident 136 ' s room. The resident's meal tray, observed at that time, did not include the Level of Harm - Minimal harm or prescribed health shake. The meal ticket accompanying the tray indicated that a health shake should be potential for actual harm included with the meal. FM1 stated, that Resident 136 did not receive the health shake with her meal.

Residents Affected - Few During a concurrent observation and interview on 1/8/2025 at 12:50 PM, with Registered Nurse 1 (RN 1) in Resident 136 ' s room, RN 1 confirmed that the health shake was not on the meal tray and requested it from

the kitchen after the oversight was identified. RN 1 stated, she shouldn ' t skip the shake, as it ' s essential for addressing her recent weight loss.

During an interview on 1/9/2025 at 4:06 PM with Dietary Supervisor (DS), stated Resident 136 does have a physician order to receive the health shake with her meals three times a day. It must have been missed accidentally. DS stated the shakes are essential for residents with weight loss to maintain proper nutrition and prevent further health complications.

During an interview on 1/10/2025 at 12:45 PM with the Director of Nursing (DON), DON stated, it was important to ensure the residents receive prescribed dietary supplements, follow the physician ' s diet orders for the residents to maintain the nutritional health, especially for those with weight loss concerns. Nutritional supplements like health shakes are a key component of their care plan and must be provided as ordered to prevent further decline.

During a review of the facility's policy and procedure (P&P) titled, Diet Orders, revised 2023, indicated that Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42854 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three (3) of 3 sampled Residents Affected - Some residents (Resident 27, 201, and 202) were provided with safety and comfort while receiving oxygen therapy,

in accordance with the facility's policy and procedure by failing to:

1. Ensure Resident 27's oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) and nasal cannula did not touch the floor.

2. Ensure Resident 201's humidifier bottle (a water bottle that aids in preventing patients' airways from becoming dry) was not empty for Resident 201.

3. Ensure Resident 202's oxygen tubing did not touch the floor.

These deficient practices had the potential for Resident 27, 201, and 202 to contract infection while receiving oxygen therapy and increase the risk of the spread of infection to other residents, staff, and the visitors in the facility.

Findings:

1. During a review of Resident 27's Admission record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included lobar pneumonia (type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung), difficulty in walking, 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.

During a review of Resident 27's History and Physical (H&P), dated 10/25/2024, indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 27's Order Summary Report, dated 12/28/2024, indicated a physician order for Oxygen therapy at 2 liters (L, unit of measure) per minute continuous every shift.

During an observation in Resident 27's room on 1/6/2025 at 9:59 AM, Resident 27's nasal cannula (medical device to provide supplemental oxygen therapy) and oxygen tubing was observed on the floor.

During a concurrent observation and interview in Resident 27's room on 1/6/2025 at 10:15 AM, the Assistant Director of Nursing (ADON) was observed placing a floor mat on the right side of resident ' s bed and on top of resident's nasal cannula and oxygen tubing. At 10:20 AM, verified with ADON of Resident 27's nasal cannula and tubing placement on the floor. ADON stated when not in use, the nasal cannula and tubing suppose to be placed in the bag for infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 2. During a review of Resident 201's Admission record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included lobar pneumonia, sepsis (a serious condition in which the body responds improperly Level of Harm - Minimal harm or to an infection), and acute erythroid leukemia (an extremely rare form of acute myeloid leukemia [type of potential for actual harm cancer of the blood and bone marrow with excess immature white blood cells] which is characterized by neoplastic proliferation [the process of excessive and uncontrolled cell proliferation] of erythroid cells [red Residents Affected - Some blood cells]) in relapse.

During a review of Resident 201's History and Physical (H&P), dated 12/26/2024, indicated the resident had capacity to understand and make decisions.

During a review of Resident 201's Order Summary Report, dated 12/28/2024, indicated a physician order for Oxygen therapy at 2 liters (L, unit of measure) per minute as needed for shortness of breath or Oxygen saturation level less than 92%. The Order Summary Report also indicated a physician order to change oxygen humidifier every day shift every 7 day(s) and to change every Thursday.

During an observation in Resident 201's room on 1/6/2025 at 10 AM, Resident 201 was observed receiving oxygen therapy via nasal cannula at 3 LPM. Observed nasal cannula and oxygen tubing attached to oxygen machine with an empty humidifier bottle dated 12/26/2024.

During a concurrent observation and interview in Resident 201's room [ROOM NUMBER]/6/2025 at 10:22 AM, verified with ADON of the empty humidifier bottle attached to Resident 201's oxygen machine. ADON stated the humidifier bottle should be changed every week.

3. During a review of Resident 202's Admission record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included pulmonary embolism without acute pulmonale, type 2 diabetes mellitus, and essential hypertension (high blood pressure).

During a review of Resident 202's History and Physical (H&P), dated 1/8/202, did not indicate if the resident had capacity to understand or make decisions.

During a review of Resident 202's Order Summary Report, dated 1/2/2025, indicated a physician order for Oxygen therapy at 2 LPM continuous every shift.

During an observation in Resident 202's room on 1/6/2025 at 11:07 AM, Resident 202 was observed receiving oxygen therapy via nasal cannula at 2 LPM. Observed Resident 202's oxygen tubing touching the floor.

During a concurrent observation and interview in Resident 202's room [ROOM NUMBER]/6/2025 at 11:21 AM, verified with licensed vocational nurse (LVN) 1 of Resident 202's oxygen tubing. LVN stated the oxygen tubing should not be on the floor to prevent spread of infection. LVN stated she would change the oxygen tubing and humidifier bottle because there was no date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview with the Director of Nursing (DON) on 1/10/2025 at 11:05 AM, the DON stated oxygen equipment should not be touching the floor because there was a concern for infection control. The DON Level of Harm - Minimal harm or stated the oxygen equipment should be replaced right away. The DON stated when not in use, the oxygen potential for actual harm tubing and nasal cannula should be placed in a plastic bag with a date of when it was opened. The DON stated the humidifier bottle should be changed every 7 days or when it was empty. The DON stated the Residents Affected - Some humidifier bottle should not be empty because it could cause nose to dry up if there was a high concentration of oxygen being given. The DON stated the humidifier bottle should also be labeled of when it was opened.

During a review of the facility's policy and procedure (P&P) titled Oxygen, use of dated 5/2021 indicated the facility will promote resident safety in administering oxygen. The P&P indicated tubing, masks, humidifiers, and other disposables used for Oxygen administration will be dated in an identifiable fashion. The P&P indicated the tubing should be kept off the floor. The P&P also indicated labeled and dated bags should be provided for cannulas and masks to be placed in when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42878

Residents Affected - Some Based on observation, interview and record review, the facility failed to reseal one intramuscular emergency kit (IM e-kit, a collection of supplies of medications that administered into the muscle in an emergency) for one of three sampled IM e-kits and replace the e-kit within 72 hours for Medication room [ROOM NUMBER].

The deficient practice had potential to result in an insufficient number of medications on hand in case of emergency and the potential to result in the inability to identify drug diversion (when a medication is taken for use by someone other than whom it was prescribed or for an indication other than what is prescribed) or misuse.

Findings:

1. During a review of Resident 251's Admission Record indicated the facility originally admitted Resident 251

on 4/16/2024 and readmitted him on 12/2/2024 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and hyperlipidemia (a condition where there are high levels of fat in the blood).

During a review of Resident 251's Minimum Data Set (MDS, a resident assessment tool), dated 12/9/2024, indicated Resident 251 had intact memory and cognition (ability to think and reason).

During a review of the facility's IM/E-KIT log, dated 9/30/2024, indicated one vial of furosemide 40 mg/ four milliliter (ml, a unit of measurement) was available and it was removed from the e-kit on 12/5/2024 at 4:20 PM and used for Resident 251.

During a review of Resident 251's Order Details, dated 12/5/2024, indicated the physician ordered to give Furosemide (a medication to treat fluid retention) 40 milligrams (mg, a unit of measurement) intramuscularly one time only on 12/5/2024.

During a review of Resident 251's Medication Administration Record (MAR), dated 12/1/2024 to 12/31/2024, indicated Resident 251 received Furosemide 40 mg inject intramuscularly one time only, dose from e-kit, on 12/5/2024.

2. During a review of Resident 48's Admission Record indicated the facility originally admitted Resident 48

on 5/22/2022 and readmitted him on 5/30/2024 with diagnoses that included diabetes mellitus and hyperlipidemia.

During a review of Resident 48's MDS, dated [DATE REDACTED], indicated Resident 48 had severely impaired memory and cognition.

During a review of the facility's IM/E-KIT log, dated 9/30/2024, indicated 1 unit of Glucagon Hypo kit (a prescription emergency kit that contains glucagon, a hormone that treats severe low blood sugar in people) 1 mg was available and it was removed from the e-kit on 12/30/2024 at 11 PM and used for Resident 48.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review Resident 48's Order Summary order, dated 12/18/2024, indicated the physician ordered if blood sugar level was less than 70 and conscious or no change in level of conscience, give Insta-Glucose (a Level of Harm - Minimal harm or gel that can raise blood sugar level quickly) orally one time, recheck blood sugar level after 15 minutes, if potential for actual harm ineffective and or unconscious, give Glucagon 1mg IM one time.

Residents Affected - Some During a review of Resident 48's Progress Notes, dated 12/30/2024, indicted skilled nurse administered Glucagon IM due to low blood sugar level.

During an interview and concurrent observation on 1/8/2025 at 2:48 PM of Medication room [ROOM NUMBER] with Registered Nurse (RN)1, One IM e-kit was observed opened with no zip tie (a fastener consisting of a thin flexible nylon strap). RN 1 stated the IM e-kit was missing the Furosemide (a medication used to reduce water retention). RN 1 stated she did not know why she did not know why and for how long

the IM e-kit was not resealed with the orange zip ties when the medication was taken out to prevent unauthorized access to the e-kit and to let the pharmacy know the e-kit had been opened and needed to be replaced.

During a telephone interview on 1/9/2025 at 10:17 AM, with the Pharmacist. The Pharmacist stated the facility started to implement the use of CUBEX (an automated unit dose system for storage and retrieval of unit doses of drugs for administration to patients) for emergency supply of medications on 12/20/2024 and

the facility was expected not to use the e-kits anymore. The pharmacist stated the pharmacy staff went to pick up all the physical e-kit boxes from the facility on 1/4/2025, but the facility did not turn in the IM e-kit on that day. The pharmacist stated they were not aware that the facility still had the e-kit and was still using it, so they did not replace the e-kit.

During an interview on 1/9/2025 at 1:50 PM, with the Director of Nursing (DON), the DON stated if the nurse opened the e-kit and used medication from the e-kit, the nurse should reseal the e-kit with the orange zip ties, so that no one else could get the access to the e-kit and remove medications from it without authorization and alert other staff a replacement of the e-kit was needed. The DON stated it was important to have emergency supply of medications available to ensure the patient received the medication when needed. The DON stated after 12/20/2024, the facility started to use CUBEX for the emergency supply of medications and did not need to use the e-kit anymore, but she did not know why the staff still opened the e-kit and removed medication from it for a patient on 12/30/2024.

During a review of the undated facility's policy and procedure (P&P) titled, Emergency Pharmacy Service and Emergency Kits, indicated an emergency supply of medications, .are supplied by the provider pharmacy

in limited quantities in portable, sealed containers, . and When an emergency or starter dose of a medication is needed, the nurse unlocks the container/cabinet, .As soon as possible, the nurse seals the E kit with a color-coded lock to indicate need for replacement of the E kit. The P&P also indicated opened kit are replaced 72 hours of opening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50012

Residents Affected - Some Based on observation and interview, the facility failed to ensure the daily refrigerator temperature logs was completed as required by its policy, compromising its ability to monitor food storage temperatures effectively.

This deficiency created a risk of unsafe food storage conditions and potential foodborne illness (caused by consuming contaminated foods or beverages) for residents.

Findings:

During initial kitchen tour with the Dietary Director (DD) on 1/6/2025 8:30 AM, observed that the refrigerator temperature logs located in the kitchen in a binder were incomplete. No temperature entries were documented for 1/4/2025 for AM and PM shift for Freezer #1.

During a concurrent interview and record review on 1/7/2025 at 8:35 AM with the DD, the Refrigeration and Freezer Temperature Log for January 2025 was reviewed. The log had missing entries were noted for the AM and PM shift on 1/4/2025. The DD stated she should have followed up the completion of the log.

During an interview on 1/7/2025 at 8:35 AM with the DS stated, Staff are expected to record refrigerator Temperatures are checked twice a day as part of our food safety protocols. Without these logs, we have no way of knowing if food has been stored at safe temperatures, which could lead to food spoilage or bacterial growth. If residents consume spoiled food, they could develop foodborne illnesses.

During a review of the facility's policy and procedure (P&P) titled, Cold Storage temperature monitoring and

record keeping , indicated, Food and Nutrition staff shall review and record temperatures of all refrigerators and freezers to ensure at the correct temperature for food storage and handling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 47 055430 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055430 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Some Based on interview, and record review, the facility ' s Quality Assessment and Assurance (QAA) committee (a group of facility staff responsible in developing and approving and evaluating established policies and procedures of resident ' s quality of care) failed to develop a policy and procedure related to admission process.

Resident 301 was admitted to the facility with diagnosis of Diabetes Mellitus (a condition of having high blood sugar) at General Acute Care Hospital (GACH) 1, which was not monitored for signs and symptoms of high or low blood sugar levels.

This failure had a potential for the residents not to receive the care and services for DM and other health concerns that could lead to a decline in the resident's well being.

Cross reference to