Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Presbyterian Intercomm Hosp Dp/snf during CMS and state inspections, most recent first.
Care view cameras were installed in the rooms of four residents with intact cognitive abilities, without proper signage, notification, or consent. Residents and family members reported not being informed or educated about the cameras, leading to discomfort and concerns about privacy. Facility policy requiring signage and education prior to camera use was not followed, resulting in a failure to honor residents' rights to dignity and respect.
A resident was not assessed completely and in a timely manner upon admission and at the required periodic intervals, specifically at least every 12 months, as mandated. This resulted in noncompliance with required assessment procedures.
A discharge tracking assessment was not completed or transmitted for a resident who was discharged after treatment for pyelonephritis and chronic respiratory failure with hypoxia. The MDS nurse confirmed the omission, which was not in accordance with facility policy requiring timely completion and transmission of the MDS discharge assessment.
A resident with diabetes and dementia receiving nasogastric tube feeding was observed with the head of bed not elevated as required by care plan, physician order, and facility policy. Staff confirmed the bed was not at the appropriate angle during feeding, resulting in a deficiency in care to prevent aspiration.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with a history of urinary retention and acute kidney injury refused a prescribed dose of Atenolol, and the administering RN did not document the refusal or notify the NP as required by facility policy. The MAR lacked both the reason for the missed dose and evidence of provider notification, despite policy stating both actions must be recorded.
A resident reported verbal abuse by a staff member to an LVN, but the incident was not reported to the Department of Health Services and state agencies within the required two-hour timeframe. The resident, who was cognitively intact and had a history of several medical conditions, felt disrespected and berated. Despite being informed, the DON did not report the incident promptly, violating the facility's policy.
The facility failed to maintain sanitary conditions in the kitchen, as an unlabeled and undated container of salad was found in the cold production refrigerator. The Supervisor Food Services acknowledged the issue, and the System Director Infection Preventionist highlighted the risk of serving expired food to residents. Facility policy requires all perishable food to be dated and labeled, and staff food must be stored separately from patient food.
A resident's dignity was compromised when their drainage bag, connected to their stomach, was left uncovered and exposed to the public. The resident, who had a history of paraesophageal hernia and required a gastrojejunostomy tube, was observed with an uncovered catheter bag containing cloudy sediments. Facility staff confirmed that the bag should have been covered to maintain dignity, as per policy.
A facility failed to provide a resident with written notification of their transfer to a GACH due to worsening edema and a-fib with RVR. The DON confirmed that the facility lacked a discharge/transfer notification document and did not have a policy for notifying residents about transfers or discharges at the time.
A resident with missing top teeth and dentures was not assessed for choking risk, leading to her being served regular textured meals, including whole pieces of meat. The facility's oversight was discovered after the resident nearly choked, prompting a review and adjustment of her diet to a soft and bite-sized texture. The facility's policy required a systematic examination of patients' conditions, which was not followed in this case.
Failure to Ensure Resident Dignity and Privacy During Video Monitoring
Penalty
Summary
The facility failed to promote dignity and respect for residents by placing care view cameras in the rooms of four residents without proper notification, consent, or signage. Observations revealed that cameras were installed directly facing residents, and in several cases, there was no posted signage inside or outside the rooms to inform residents, families, or visitors of the video surveillance. Interviews with residents and their family representatives indicated that they were not educated about the cameras prior to their use, and some residents expressed discomfort, a sense of lost privacy, and concerns about being watched without their knowledge or consent. Resident records showed that all four affected residents had intact cognitive skills for daily decision-making and required varying levels of assistance with activities of daily living. Despite this, none of the residents recalled being informed about the cameras or signing any consent forms. One resident compared the experience to being watched in a bathroom, while another stated that the only privacy they had was when staff called to have the camera turned off during personal care. Family representatives also confirmed a lack of education or notification regarding the cameras. Facility policy required that signs be posted in rooms where video monitoring was in use and that residents or their representatives be educated prior to camera activation. However, staff interviews and observations confirmed that these procedures were not consistently followed. The Director of Nursing acknowledged that there was no official consent process and that signage and education should have been provided before cameras were used. This failure resulted in residents experiencing discomfort and a lack of personal privacy, in direct violation of their rights to dignity, self-determination, and communication.
Failure to Complete Timely Resident Assessments
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and then periodically, at least every 12 months, as required. The report notes that the necessary comprehensive assessment was not conducted according to the specified timeframes, resulting in noncompliance with assessment protocols.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge tracking assessment for one of five sampled residents. Specifically, a resident who was admitted with diagnoses of pyelonephritis and chronic respiratory failure with hypoxia was discharged from the facility, but the required Minimum Data Set (MDS) discharge tracking assessment was not completed or transmitted within the mandated 14-day period following discharge. This was confirmed during an interview and record review with the MDS nurse, who acknowledged that the assessment was not done as required. Review of the facility's policy and procedure indicated that the Resident Assessment Instrument (RAI) process, which includes the MDS, must be completed timely and accurately for all residents, including at discharge. The policy specifies that the discharge MDS assessment is due within 14 calendar days of the discharge date. The failure to complete and transmit the discharge assessment was a direct violation of this policy and federal requirements.
Failure to Maintain Proper Bed Elevation During Tube Feeding
Penalty
Summary
A resident with diabetes mellitus and dementia was admitted to the facility and was receiving nutrition via a nasogastric tube (NGT) at a continuous rate of 40 ml/hour of Glucerna. The resident's care plan and physician's orders specified that the head of the bed (HOB) should be elevated to at least 30 degrees during tube feeding to prevent aspiration. During observation, the resident was found sliding down in bed with the HOB not elevated as required while receiving tube feeding. Certified Nursing Assistant 3 confirmed that the resident's head was not at the appropriate angle and acknowledged it should have been at 30 degrees. Both the Registered Nurse and the Director of Nursing stated that the HOB should be at least 30 degrees or higher during tube feeding, in accordance with facility policy. A review of the facility's policy on enteral feedings indicated that patients should be positioned with the backrest elevated to a minimum of 30 degrees, preferably 45 degrees, prior to and during enteral feeding. Despite these clear directives, staff failed to maintain the required bed elevation for the resident during NGT feeding, as observed by surveyors. This failure to follow established protocols and physician orders constituted a deficiency in care for the resident receiving tube feeding.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Document Medication Refusal and Provider Notification
Penalty
Summary
A deficiency was identified when a resident, admitted with urinary retention and acute kidney injury, refused a prescribed dose of Atenolol, a medication used to treat high blood pressure. The resident's Minimum Data Set indicated intact cognitive skills and varying levels of assistance required for daily activities. During a medication pass, the resident's systolic blood pressure was measured at 108 mmHg, above the threshold for holding the medication, but the resident refused the dose, stating his blood pressure was acceptable. The facility's Medication Administration Record did not document the reason for the missed dose or the notification of the Nurse Practitioner regarding the resident's refusal, as required by facility policy. Interviews with the administering RN and the Clinical Nurse Manager confirmed that the NP was not notified and that this omission was not documented. Facility policy specifies that any refusal of medication and physician notification must be recorded in the MAR, but this was not done in this instance.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Department of Health Services and state agencies within the required two-hour timeframe as per the facility's policy. The incident involved a resident who was cognitively intact and able to express ideas and wants. The resident reported to a Licensed Vocational Nurse (LVN) that a staff member yelled at him and was mean, which the resident perceived as verbal abuse. Despite being informed of the allegation, the Director of Nursing (DON) did not report the incident to the appropriate authorities in a timely manner. The resident, who had a history of acute cerebral vascular accident, hypertension, coronary artery disease, hemiplegia, hemiparesis, congestive heart failure, and major depressive disorder, was alert and oriented at the time of the incident. The facility's policy mandates that all employees are required to report any known or suspected abuse immediately, but no later than two hours if it involves abuse. The DON acknowledged the importance of reporting such allegations to ensure the safety of the resident and prevent further abuse, yet the report was not made as required.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as observed during an initial tour. An opened container of salad was found in the cold production refrigerator without a label indicating the name of the food item or the date it was prepared or should be discarded. The Supervisor Food Services (SFS) acknowledged that the container might belong to a staff member and should not be stored in the cold production refrigerator if it was personal. The SFS also confirmed that all food items should be labeled and dated. During an interview, the System Director Infection Preventionist (SDIP) emphasized the importance of labeling and dating food items to prevent serving expired food to residents, which could expose them to foodborne illnesses. A review of the facility's policy and procedure on food supplies indicated that all perishable food must be dated, and items not commercially labeled should have a label stating the date and contents. Additionally, staff food must be kept separate from patient food and should not be stored in patient refrigerators or freezers.
Failure to Maintain Resident Dignity by Not Covering Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident by not ensuring that the resident's drainage bag was covered and not exposed to the public. During an initial tour, it was observed that the resident's catheter bag, which was connected to the resident's stomach, was hanging uncovered from the bed frame, with cloudy sediments visible in the tubing and bag. This observation was made despite the facility's policy that catheter bags should always have a privacy cover for dignity reasons. The resident involved had a history of paraesophageal hernia and had undergone a gastrojejunostomy tube placement. The resident's cognitive function was moderately intact, and they required maximal assistance with lower body dressing and toilet hygiene. Interviews with the Licensed Vocational Nurse and the Director of Nursing confirmed that the catheter bag should have been covered at all times to maintain the resident's dignity, as per the facility's policy on patient rights and responsibilities.
Failure to Notify Resident of Transfer/Discharge
Penalty
Summary
The facility failed to provide timely written notification to Resident 13 regarding their transfer or discharge to a General Acute Care Hospital (GACH). Resident 13 was admitted to the facility with diagnoses including atrial fibrillation with rapid ventricular rate (a-fib with RVR) and was discharged to the cardiac unit of a GACH due to worsening edema and a-fib with RVR. However, the facility did not have a discharge/transfer notification document at the time of Resident 13's discharge, and thus, the resident was not informed in writing about the transfer or discharge. During an interview and record review, the Director of Nursing (DON) confirmed that the facility lacked a discharge/transfer notification document when Resident 13 was discharged. The DON acknowledged that the facility did not have a policy and procedure for notifying residents about their transfer or discharge at that time. The facility's Transitional Care Unit Notice of Proposed Transfer/Discharge document was only created after the incident, indicating that the necessary documentation and procedures were not in place when Resident 13 was transferred.
Failure to Assess Choking Risk for Resident with Missing Dentures
Penalty
Summary
The facility failed to assess the risk of accidental choking for a resident who was missing her top teeth and dentures. This resident, identified as Resident 116, was admitted to the facility with a diagnosis of chest pain and required physical therapy, occupational therapy, and wound care. Despite these needs, the facility did not document the resident's dental status in her electronic medical record, and she was served regular textured meals, which included whole pieces of meat. This oversight was highlighted when the resident's representative expressed concern after the resident nearly choked on uncut chicken served for dinner. Interviews with facility staff revealed that the nursing staff did not assess the resident's ability to chew food upon admission, and there was no indication that speech therapy had evaluated her dietary needs. The Assistant Director of Nursing acknowledged the importance of assessing residents' dental status to prevent aspiration risks. It was only after the surveyor's intervention that a registered nurse assessed the resident's chewing ability and adjusted her diet to a soft and bite-sized texture. The facility's policy required a systematic examination of patients' conditions, but this was not adhered to in the case of Resident 116.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Whittier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchard - Post Acute Care | 0 mi | ★★★★★ | 3 | 0 |
| Whittier Pacific Care Center | 0.6 mi | ★★★★★ | 20 | 0 |
| Whittier Nursing And Wellness Center, Inc | 1.2 mi | ★★★★★ | 8 | 0 |
| Socal Post-acute Care | 1.5 mi | ★★★★★ | 22 | 0 |
| Pico Rivera Healthcare Center | 2.8 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.