Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Whittier Hospital Medical Ctr D/p Snf during CMS and state inspections, most recent first.
The facility failed to follow its equipment cleaning policy when staff did not disinfect a shared electronic vital signs machine between residents, contributing to a cluster of rhinovirus cases. Three medically complex residents with tracheostomies, ventilator dependence, and feeding tubes developed symptoms such as fever, increased secretions, respiratory distress, and elevated blood pressure, and each later tested positive for rhinovirus via nasopharyngeal specimens. During an investigation, the IP identified the common use of the same vital signs machine without disinfection as the shared factor, and a CNA acknowledged not cleaning the device between residents despite understanding its role in preventing illness transmission.
A resident with chronic lung disease and ventilation dependency experienced persistent redness and scratches on the chest and abdomen. Despite nursing staff placing wound care consults, there was no documentation of assessment by the wound care team, contrary to the facility's policy. The resident's mother requested measures to prevent further scratching, but the facility's procedures were not followed.
The facility failed to ensure that two residents had completed advance directive acknowledgment forms. One resident with anoxic brain damage and another with spastic quadriplegic cerebral palsy did not have these forms in their medical records. The Social Services Director was unable to locate the forms, and the Director of Nursing emphasized their importance for emergencies.
The facility failed to label G-tube feeding syringes with the date opened for four residents and did not replace a feeding bottle for one resident within the required 24-hour period, risking infection and contamination.
The facility failed to ensure that the Attending Physician reviewed and documented the rationale for accepting or rejecting the pharmacist's recommendations in the Medication Regimen Review for multiple residents. This deficiency was observed in residents with complex medical conditions, leading to potential medication errors.
The facility failed to ensure safe and sanitary food storage, labeling, and preparation practices. Observations revealed an unlabeled ice cream cone, food particles in the freezer, wilted cilantro, molded jicama in the refrigerator, and an opened personal beverage cup in the kitchen. The Dietary Supervisor confirmed these practices were against the facility's policies.
The facility failed to maintain a safe, sanitary environment to prevent infections. A housekeeper did not wear proper PPE or perform hand hygiene when entering rooms of residents on isolation precautions. A CNA did not change PPE or wear an N95 mask while feeding a resident. The DON confirmed that wearing N95 masks in patient care areas was a facility practice.
The facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for a resident with a urinary catheter. The resident had a short-term care plan for UTI that mentioned the urinary catheter but lacked specific interventions and goals. The resident's care plan was not individualized, and the facility's policy on updating care plans was not followed.
The facility failed to ensure proper respiratory care for a resident with DiGeorge syndrome, seizure disorder, and asthma. The resident's tracheostomy mask was improperly stored, and the aerosol oxygen system was undated, contrary to facility practices and policies, placing the resident at risk for infection.
Failure to Disinfect Shared Vital Signs Equipment Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff adhered to its infection prevention and control program and equipment cleaning policy when multiple residents tested positive for rhinovirus within a four-day period. The facility’s policy titled “Equipment Cleaning Guidelines,” last reviewed in May 2022, required that medical equipment used in a patient room or that comes into contact with the patient or the contaminated environment be cleaned and disinfected before being used on any other patient. Despite this policy, staff were observed not disinfecting a shared electronic vital signs machine between residents. Three residents with complex medical conditions were involved. One resident, admitted with a history including Trisomy 21, cerebral palsy, global developmental delay, seizures, GJ-tube dependence, chronic respiratory failure with tracheostomy/ventilator dependence, and recurrent aspiration pneumonia, developed initial symptoms of fever, increased secretions, and increased oxygen needs. A nasopharyngeal specimen collected later tested positive for rhinovirus. A second resident, with a history including extreme prematurity at 24 weeks’ gestation, tracheobronchomalacia, tracheostomy tube placement, ventilator dependence, and gastrostomy tube dependence, developed rhinorrhea, labored breathing, cough, wheezing, and increased oxygen demand; this resident’s nasopharyngeal specimen also tested positive for rhinovirus. A third resident, with a history of hypoxic-ischemic encephalopathy after a near-drowning event, tracheostomy tube placement, gastrostomy tube placement, and tracheostomy/ventilator dependence, had elevated blood pressure readings and underwent nasopharyngeal testing as part of a differential diagnosis, which also returned positive for rhinovirus. During the Infection Preventionist’s investigation into a common factor among the three residents, the use of a common electronic vital signs machine was identified as the shared element. The Infection Preventionist stated that staff were observed not disinfecting this vital signs machine between resident uses, contrary to facility policy. A CNA confirmed in interview that, prior to the rhinovirus outbreak involving these residents, they did not disinfect the vital signs machine between residents, despite acknowledging the importance of doing so to prevent the spread of illness.
Failure to Implement Wound Care Policy for Resident
Penalty
Summary
The facility failed to ensure that a resident's skin integrity was assessed and treated by wound care services as per the facility's policy and procedure. The resident, an 8-month-old with chronic lung disease, a tracheostomy, and ventilation dependency, exhibited persistent redness and scratches on the chest and abdomen. Despite nursing staff placing a wound care consult on two occasions, there was no documentation that the wound care team assessed the resident. The nursing notes indicated multiple instances of redness and scratches, and the resident's mother requested measures to prevent further scratching. However, the facility's policy on skin screening, prevention, and treatment, which outlines the responsibilities of the wound care specialist, was not implemented for this resident. The Chief Nursing Officer confirmed the lack of documentation for wound care assessment, highlighting a failure in following the established procedures for wound care consultation and treatment.
Failure to Complete Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to ensure that two of four sampled residents had a completed advance directive acknowledgment form. Resident 15, who was readmitted with anoxic brain damage, did not have an advance directive in their medical records. The Social Services Director (SSD) was unable to locate the form and was unsure when the responsible party had signed it. This oversight was discovered during a concurrent interview and record review with the SSD. Similarly, Resident 19, admitted with spastic quadriplegic cerebral palsy, also lacked an advance directive decision form in their medical records. The SSD confirmed that the responsible party had not signed the form upon admission and had not followed up. The Director of Nursing (DON) emphasized the importance of having these forms on file for emergencies. The facility's policy, revised in October 2021, supports the right to self-determination in healthcare decisions through the use of advance directives.
Failure to Label G-Tube Syringes and Replace Feeding Bottles Timely
Penalty
Summary
The facility failed to provide appropriate care for four residents with gastrostomy tubes (G-Tubes) by not labeling the tube feeding syringes with the date they were opened. During observations, it was noted that the syringes for Residents 4, 9, 11, and 12 were not labeled, which was confirmed by Licensed Vocational Nurse (LVN) 1. LVN 1 acknowledged the importance of labeling to avoid cross-contamination and ensure syringes were not used for too many days. The Director of Nursing (DON) also confirmed that all equipment used for G-tubes, including syringes, should be labeled with the date opened to minimize bacteria growth and infection risk. Additionally, the facility failed to ensure that a new bottle of Peptide-Based Nutrition was used for Resident 4 within the required 24-hour period. An observation revealed that Resident 4's Pediasure Peptide bottle was dated 4/10/2024 at 7:30 PM, indicating it had been in use for more than 24 hours. LVN 2 confirmed that the bottle should be changed every 24 hours to prevent infection or bacterial growth. The DON reiterated that the staff must dispose of the syringe and bottle feeding at 24 hours to minimize bacteria growth. The facility's policy and procedure titled Tube Feedings, dated 5/31/2007, indicated that the maximum hanging time for a closed system (bottle) was 24 hours. The failure to adhere to this policy and properly label equipment placed the residents at risk for infection and other complications related to G-tube care. The observations and interviews with the staff highlighted these deficiencies in the facility's practices regarding G-tube management and infection control protocols.
Failure to Document Medication Regimen Review Decisions
Penalty
Summary
The facility failed to ensure that the Attending Physician (AP) reviewed the drug regimen thoroughly and documented in the resident's medical record whether the identified irregularities and recommendations of the pharmacist were accepted or rejected, along with a rationale. This deficiency was observed in four sampled residents. For Resident 9, the AP signed the Medication Regimen Review (MRR) documents but did not provide a rationale for accepting or rejecting the pharmacist's recommendations on multiple occasions. Similar issues were found with Resident 5, where the AP signed the MRR but did not document the rationale for the pharmacist's recommendations regarding medication adjustments for constipation and Vitamin D supplementation. Resident 3's records showed that the AP signed the MRR for an increase in ibuprofen dosage but did not provide a rationale for the decision. Resident 10's records indicated that the AP signed the MRR for an increase in Tylenol dosage but again failed to document whether the pharmacist's recommendations were accepted or rejected, along with the rationale. During an interview, the Director of Nursing (DON) acknowledged the importance of completing the MRR to prevent medication errors and stated that the charge nurses, clinical managers, and herself review the MRR for compliance. The facility's policy and procedure titled Pharmacy Drug Audits required the physician or nurse practitioner to review the pharmacist's recommendations and either accept or reject them, documenting the clinical reason for any rejections. However, this policy was not followed, leading to the potential for residents to receive incorrect medication dosages or not receive the appropriate medication for their conditions. This failure to document the rationale for medication decisions could result in significant harm to the residents.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage, labeling, and preparation practices in the kitchen. During an initial observation, an opened unlabeled plastic container with a single ice cream cone was found in the freezer, and food particles were observed on the freezer floor. The Dietary Supervisor (DS) confirmed that all food should be labeled with the use-by and open date and that the freezer floor should be cleaned daily to prevent cross-contamination. Additionally, a bundle of wilted black-colored cilantro and a molded jicama were found in the refrigerator, which the DS acknowledged should be removed daily to maintain food quality and prevent contamination. Further observations revealed an opened personal beverage cup containing an unknown red liquid on the food prep table in the kitchen. The DS stated that dietary staff should not have opened personal beverage containers in the kitchen, especially during lunch prep time, as it could lead to food contamination. The facility's policy and procedure on Cleaning Schedule Use and Cleaning of Equipment indicated that floors should be swept daily and refrigerators should be checked daily for freshness, which was not adhered to in this instance.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain a safe, sanitary environment to prevent the spread of infections. Housekeeper 1 did not wear a surgical facemask properly, failed to don an N95 respirator when entering patient care areas, and did not change gloves or perform hand hygiene when entering rooms of residents on contact and droplet isolation precautions. Specifically, Housekeeper 1 was observed entering Resident 18's room without proper PPE and touching her face mask with dirty gloves. She also entered the rooms of Residents 9, 11, and 14 without changing gloves or donning an isolation gown, and did not perform hand hygiene during the entire observation period. Housekeeper 1 was unable to explain why she did not follow proper infection control procedures. Certified Nursing Assistant 1 also failed to follow infection control protocols. CNA 1 did not doff dirty PPE or perform hand hygiene when exiting Resident 13's room and re-entered the room without changing PPE. Additionally, CNA 1 was observed feeding Resident 13 while wearing a surgical mask instead of the required N95 respirator. CNA 1 admitted to forgetting to change her mask and acknowledged the importance of wearing an N95 mask to protect vulnerable residents from diseases. The Director of Nursing confirmed that while the facility did not have a written policy requiring N95 masks, it was a facility practice to wear them in patient care areas as indicated by signage. The facility's Infection Prevention and Control Plan aimed to reduce infection incidences and provide a safe environment, but these protocols were not followed by the staff, leading to potential contamination and spread of infection among residents, staff, and visitors.
Failure to Develop Individualized Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan with measurable objectives, timeframes, and interventions for a resident with a urinary catheter. The resident, who was readmitted to the facility with diagnoses including anoxic brain damage, neurogenic bladder, and a urinary tract infection (UTI), did not have a specific care plan addressing the urinary catheter. Instead, the resident had a short-term care plan for UTI that mentioned the urinary catheter but lacked specific interventions and goals. During an observation and interview, it was noted that the resident's urinary catheter was hanging from the lower left side of the bed frame, and the resident was receiving intravenous antibiotics for recurrent UTIs. The Minimum Data Assistant (MDSA) confirmed that the resident's care plan was not individualized and did not include measurable goals, timeframes, or specific interventions. The facility's policy indicated that care plans should be updated with any change in needs or care, but this was not followed in the resident's case.
Improper Respiratory Equipment Handling
Penalty
Summary
The facility failed to ensure proper respiratory care for Resident 13, who had a diagnosis of DiGeorge syndrome, seizure disorder, and asthma. During an observation, it was noted that Resident 13's tracheostomy mask was improperly stored between the crib rails and touching the space between the mattress and crib rails, instead of being placed inside a storage bag as per facility practice. This improper storage was confirmed by an LVN, who stated that the mask should be stored in a bag to prevent contamination and infection. Additionally, the resident's aerosol oxygen system was found to be undated, contrary to the facility's policy that requires these systems to be changed and dated every week on Tuesdays. This was confirmed by a Respiratory Therapist who acknowledged the missing date label on the system. Further interviews with the Respiratory Therapist Lead and the Director of Nurses confirmed that it is the facility's practice to store the tracheostomy mask in a bag when not in use and to date the aerosol oxygen systems to verify they were changed according to policy. The facility's policy on Respiratory Equipment Handling, revised in 2018, also indicated that aerosol oxygen systems are to be changed on Tuesdays. The failure to adhere to these practices placed Resident 13 at risk for infection due to potential contamination of respiratory equipment.
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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) |
|---|---|---|---|---|
| Whittier Hills Health Care Ctr | 1.8 mi | ★★★★★ | 35 | 0 |
| Whittier Nursing And Wellness Center, Inc | 1.8 mi | ★★★★★ | 8 | 0 |
| Whittier Pacific Care Center | 2.4 mi | ★★★★★ | 20 | 0 |
| Imperial Healthcare Center | 2.7 mi | ★★★★★ | 1 | 0 |
| The Orchard - Post Acute Care | 2.9 mi | ★★★★★ | 3 | 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.