Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
Food storage and dishwashing sanitation failures were identified when thermometers were missing from two refrigerators, a pitcher of iced tea remained past its use-by date, the wrong and expired test strips were used to check QUAT sanitizer, and the dishwasher temperature log lacked a PM entry. During observation, the dishwasher gauges were misread and the actual wash and rinse temperatures were below the accepted ranges, while an LPN reported the machine had been below range for a while.
A resident with impaired cognition and dependence for multiple ADLs was observed in a shared room with privacy curtains pulled back, leaving the resident exposed to other residents and visitors. The resident’s nephrostomy bag was hung without a dignity bag, and the RNCM confirmed it was exposed; the CNO stated dignity bags had been purchased for Foley and nephrostomy bags, but no policy had been developed for their use.
A resident receiving Sertraline for depression did not have a specific, measurable target behavior identified in the order or care plan, and staff were not monitoring a consistent behavior associated with the medication. The resident’s chart showed the antidepressant was continued for depression, but the record lacked behavior-specific documentation, the restraint review outcomes were left blank, and staff gave differing descriptions of the resident’s depression-related behaviors while confirming there was no formal monitoring in place.
Medication administration was not completed as ordered for a resident with HTN and pulmonary HTN who was dependent for multiple ADLs and received meds via G-tube. An RN gave Miralax with less water than ordered and did not administer all of the multivitamin because it clumped in the cup; the RN said she believed the resident had fluid restrictions, but the RNCM found no active or canceled fluid restriction order in the chart.
Pharmacist Failed to Report Irregularities in Sertraline Review: A resident with depression was prescribed Sertraline, but the order did not identify specific behaviors or symptoms tied to the diagnosis and did not include behavior monitoring instructions. Monthly MRRs did not document irregularities or a rationale for continued use, and the pharmacist stated reviews relied mainly on MD and psychiatrist notes. The CM could not find documentation justifying ongoing use, and the CNO confirmed the lack of specific behavior monitoring was not identified in the pharmacist’s written reports.
Medication administration errors exceeded the allowed rate when an RN gave a resident’s Miralax with less water than ordered and did not fully administer a multivitamin via G-tube. The resident had HTN and pulmonary HTN, and the RN stated she believed the resident was on fluid restrictions, but no active or canceled fluid restriction order was found in the record.
Dishwasher 2 was observed testing a pink sanitizing solution with an expired chlorine test strip that was not the correct strip for the QUAT sanitizer. He did not know how long to keep the strip in the solution and could not recall the last in-service on sanitizer testing. The DFN stated the facility was out of the correct QUAT test strips and had no skill check in place for verifying sanitizer strength.
QAA committee meetings were not held quarterly as required, and the required members were not regularly present. The CNO stated she was covering for the DON while the DON was on leave, but sign-in sheets showed meetings without the DON or covering DON, the IP, or the administrator/board member in attendance. The CNO also stated scheduling conflicts prevented the meetings from occurring on time, despite knowing quarterly QAPI meetings were required.
Failure to review the IPCP annually occurred when the facility used an outdated Pediatric Subacute Infection Prevention Program instead of reviewing and revising it for the next program year. The IPN stated infection control policies were reviewed every 3 years and could not recall the last IPCP review, while the CNO acknowledged the IPCP was outdated and should have been updated for the following year. The facility policy stated the IPCP is to be reviewed annually and as needed to ensure quality and compliance with recommendation and practice guidelines.
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.
Food Storage and Dishwashing Sanitation Failures
Penalty
Summary
The facility failed to keep reliable thermometers inside refrigerators 1 and 2 during a kitchen tour and interview with the Director of Food and Nutrition Services. The Director stated thermometers should be inside the refrigerators so staff can compare the internal temperatures with the external gauges and document the readings in the temperature logs. The Dietary Supervisor stated the refrigerators had recently been replaced and the thermometers were forgotten and not put back inside. A pitcher of iced tea labeled with a prepared date of 6/4/2026 and a use-by date of 6/8/2026 was observed in refrigerator 2 during a concurrent observation and interview with the Director of Food and Nutrition Services. The Director stated the pitcher should have been discarded on 6/8/2026. The Director later stated that if expired food or drink remained in the refrigerator, there was a potential risk that service staff could serve it to residents. The facility also failed to use the correct test strip to check the quaternary ammonium sanitizer in the three-compartment sink area. Dishwasher 2 demonstrated testing the pink sanitizing solution with a bottle labeled Ecolab Chlorine Test Strip, and the strip did not change color. The Director stated the bottle had expired in 2019 and that the strip used was not the correct one, adding that the facility was currently out of the correct strips. In addition, the Dishwasher machine Temperature Log for June 2026 showed no PM temperature check on 6/8/2026. During observation, Dishwasher 1 misread the dishwasher gauges, and the Maintenance Manager clarified that the actual wash and rinse temperatures were 135 F and 152 F, below the acceptable ranges of 150-165 F for wash and 160-190 F for rinse. Dishwasher 1 stated the machine had been below the accepted range for a while and often took more than 30 minutes to reach the proper temperature.
Resident’s nephrostomy bag left exposed in shared room
Penalty
Summary
The facility did not provide privacy for one of one sampled resident reviewed for dignity when Resident 1’s nephrostomy bag was exposed. Resident 1 was admitted with diagnoses including urinary tract infection and epileptical spasm. The Minimum Data Set dated 4/05/2026 indicated Resident 1’s cognition could not be assessed and that the resident was dependent for eating, oral hygiene, toileting, showering, and upper and lower body dressing. During an observation on 6/09/2026 at 10:29 AM in Resident 1’s shared room with four residents present, Resident 1 was lying in bed with the privacy curtains pulled back, leaving the resident exposed to the other residents in the room. Resident 1’s nephrostomy bag was hung on the right side of the bed without a dignity bag. During a concurrent observation and interview, the RNCM stated the nephrostomy bag did not have a dignity bag, leaving it exposed to other residents and visitors because the privacy curtain was pulled back. The CNO later stated the facility had purchased dignity bags for Foley catheter and nephrostomy bags and that dignity bags should be placed over urine drainage bags to protect resident dignity, but the facility had not developed a policy for placing a dignity bag over the urine drainage bag.
Psychotropic Medication Lacked Specific Behavior Monitoring
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary medication use by not identifying a specific, measurable target behavior for Sertraline, which was ordered for depression. The resident was admitted with a diagnosis that included depression, and the MDS dated 4/26/2026 indicated intact cognition and dependence in eating, toileting hygiene, and personal hygiene. The order summary showed Sertraline HCL solution 125 mg by mouth nightly for depression, but the order did not identify the specific behaviors or symptoms associated with the diagnosis and did not direct staff to monitor any specific behavior. The resident’s interdisciplinary review of chemical/physical restraints documented a meeting on 4/17/2026 to review chemical restraint use of Sertraline, but the outcomes of restraint use for the period 1/17/2026 to 4/17/2026 were left blank. During observation on 6/9/2026, the resident was lying in bed watching an iPad. During a concurrent interview and record review on 6/10/2026, the RNCM stated there was no care plan addressing the resident’s depression or outlining how staff should monitor the specific behaviors associated with the condition. Staff interviews confirmed inconsistent understanding of the resident’s depression-related behaviors and a lack of monitoring documentation. An LVN stated the resident’s depression presented as talking less than usual or refusing to get up into his wheelchair, and that she only documented whether the resident was up in his wheelchair. Another LVN stated the resident would not want to wake up in the morning and would refuse care, while an RN stated the resident would refuse food and would not want to interact with her, but also confirmed there was no monitoring in place for specific behaviors associated with the diagnosis of depression. The CNO stated that each psychotropic medication must have a clearly identified behavior it is intended to address and that consistent monitoring and documentation are needed to determine effectiveness, while the facility policy required the physician to identify the specific behavior, the care plan to identify the behavior disorder and medication, and nursing to document effectiveness and adverse reactions each time the drug is given.
Medication Administration Not Given as Ordered via G-Tube
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when Resident 16 did not receive medications as ordered during a medication pass observation. Resident 16 was admitted with diagnoses including hypertension and pulmonary hypertension, and the MDS indicated cognition could not be assessed and the resident was dependent for eating, oral hygiene, toileting, showering, and upper and lower body dressing. The physician’s orders included Miralax 8.5 grams daily via G-tube for constipation, mixed with 4-8 ounces of water, and a pediatric chewable multivitamin once daily via G-tube. During the observed medication administration, the RN gave Miralax with only 2 ounces of water and then flushed the G-tube with water before administering the multivitamin. After the multivitamin was given, medication remained in the cup. In interview, the RN stated the multivitamin was not fully administered because it clumped and was hard to give via G-tube, and stated Miralax was not given with 4-8 ounces of water because the resident was on fluid restrictions. The RNCM later stated there was no active or canceled fluid restriction order in the resident’s record. The CNO stated licensed nurses should follow medication orders, that the medication cup should have been rinsed with extra water to ensure all of the multivitamin was administered, and that the physician should have been contacted to clarify any suspected fluid restriction.
Pharmacist Failed to Report Irregularities in Sertraline Review
Penalty
Summary
The facility failed to ensure that the licensed pharmacist identified and reported irregularities during the monthly medication regimen review for one resident receiving Sertraline for depression. The resident was admitted with a diagnosis that included depression, had intact cognition on the MDS, and was dependent for eating, toileting hygiene, and personal hygiene. The physician’s order directed staff to administer Sertraline HCL solution 125 mg by mouth nightly, but the order summary did not identify specific behaviors or symptoms associated with depression and did not include an order to monitor for any specific behavior related to the condition. Monthly medication regimen reviews dated 1/6/2026, 2/5/2026, 3/9/2026, 4/2/2026, 5/2/2026, and 6/4/2026 did not document any irregularities related to the resident’s Sertraline use and did not include a documented rationale supporting continued use of the medication. During interview, the pharmacist stated that monthly reviews relied solely on the attending physician’s progress notes and the psychiatrist’s notes, and that nursing information was only considered if there were significant changes observed in the resident. The pharmacist also stated that the physician was responsible for documenting the rationale for continuing the medication. The case manager stated that she could not find documentation from the attending physician or psychiatrist justifying continued Sertraline use. The CNO reviewed the monthly medication regimen reviews and confirmed that the pharmacist did not identify the lack of specific behavior monitoring for the resident’s Sertraline use in the written reports to the facility. The CNO stated that behavior should be specific to the resident and confirmed that there was no documented rationale to justify continued use of Sertraline.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with 2 medication errors identified out of 25 observed medication administration opportunities for Resident 16, resulting in an 8% error rate. Resident 16 was admitted with diagnoses including hypertension and pulmonary hypertension, and the MDS indicated the resident’s cognition could not be assessed and that the resident was dependent for eating, oral hygiene, toileting, showering, and upper and lower body dressing. During medication pass observation, RN 3 administered Miralax mixed in 2 ounces of water even though the order specified mixing 8.5 grams daily via G-tube with 4 to 8 ounces of water. RN 3 then administered a multivitamin via G-tube, but medication remained in the cup after administration. RN 3 stated she did not give all of the multivitamin because it clumped and was hard to administer through the G-tube, and she said she used less water for Miralax because she believed the resident was on fluid restrictions. The RNCM later stated there was no active or canceled fluid restriction order in the resident’s medical record.
Dishwasher Not Competent to Verify QUAT Sanitizer Strength
Penalty
Summary
The facility failed to ensure that one of ten dishwashers was competent in food and nutrition service duties when Dishwasher 2 did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT) sanitizer and did not know the procedure for testing the sanitizer strength. During a kitchen tour and interview, two sink areas were observed: one three-compartment sink area used to clean and sanitize cooking pots and pans by hand, and a separate area used to clean and sanitize residents’ dishes and utensils with the dishwasher. During observation in the three-compartment sink area, Dishwasher 2 demonstrated how he normally tested the pink chemical sanitizing solution by removing a paper test strip from a bottle labeled Ecolab Chlorine Test Strip and dipping it into the solution. The strip did not change color, and Dishwasher 2 stated it was supposed to turn purple immediately and that he did not know how long to keep it in the solution. He also stated he could not remember the last time he received in-service training on testing the sanitizing solution. The Director of Food and Nutrition Services stated the test strip used was not the correct strip, that the bottle had expired in 2019, and that the facility was out of the correct QUAT sanitizer test strips. The Director also stated there was no skill check in place for verifying the QUAT sanitizing solution and that the dishwasher was required to be competent in checking the solution to ensure it remained in the critical 150-400 PPM range.
QAA Committee Did Not Meet Quarterly With Required Members Present
Penalty
Summary
The facility failed to have the Quality Assessment and Assurance (QAA) group meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, and the required committee members were not in regular attendance at the QAA meetings. During interview, the Chief Nursing Officer (CNO) stated she was covering for the DON while the DON was on leave since May 2026, and she also stated the last QAA meeting had been held in May, but she was unable to attend because of scheduling conflicts. The facility’s QAA attendance sign-in sheets were reviewed and showed that the meetings dated 7/10/2025, 12/18/2026, and 5/07/2026 did not document attendance by the DON or covering DON, the Infection Preventionist (IP), or the facility administrator or board member. During the interview, the CNO stated she was the one who attended the facility’s QAA meetings acting as the board member/administrator, but she had been unable to attend the meetings held on 7/10/2025, 12/18/2025, and 5/07/2025 due to scheduling conflicts. She acknowledged that QAPI committee meetings had to occur quarterly, but stated the facility was unable to schedule them on time because of scheduling conflicts. The facility’s policy titled Performance Improvement Plans, revised 2/2026, stated that the governing body was ultimately responsible and accountable for oversight and priority setting for the safety and quality of care, treatment, and services provided.
Failure to Review IPCP Annually
Penalty
Summary
The facility failed to review its infection prevention and control program (IPCP) annually in accordance with its policies and procedures titled, Pediatric Subacute Infection Prevention Program 2024-2025. During an interview, the Infection Prevention Nurse stated that the facility's infection control policies and procedures are reviewed every three years and could not remember the last time she reviewed the IPCP. During a concurrent interview and record review, the Chief Nursing Officer acknowledged that the facility was using an outdated IPCP and stated that the program should have been reviewed and revised in 2025 for use during 2025-2026. The facility's undated Pediatric Subacute Infection Prevention Program 2024-2025 stated that the infection prevention and control plan is part of the facility's overall commitment to quality and is intended to identify infections, opportunities for disease transmission, implementation of prevention and control interventions, and education to reduce infections and provide a safe environment for residents, families, and staff. The policy also stated that the Pediatric Subacute infection prevention and control plan will be reviewed annually and as needed to ensure quality and compliance with recommendation and practice guidelines.
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 | ★★★★★ | 36 | 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 | ★★★★★ | 5 | 0 |
| The Orchard - Post Acute Care | 2.9 mi | ★★★★★ | 3 | 0 |
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