Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Whittier Nursing And Wellness Center, Inc during CMS and state inspections, most recent first.
RN coverage was not maintained for 8 consecutive hours on multiple weekends, and record review showed no RN or DON coverage for the required time on several dates. The DON stated the facility did not require weekend RN coverage because it was small and said she sometimes forgot to sign in when she was at the facility. Staffing sheets and timecards did not document the required RN/DON presence, and the facility policy stated the DON is responsible for nursing supervision.
Inaccurate Nurse Staffing Data Posted: The facility posted an untitled staffing sheet in the lobby showing projected RN, LVN, and CNA staffing for each shift, but it did not include the actual time worked for the prior day and was not updated later in the day. The DSD stated the sheet was a projection prepared by the night shift nurse, and the DON confirmed the facility was posting projected hours rather than actual staffing hours, despite the P&P requiring actual hours worked to be posted in a prominent location.
Improper Food Labeling and Storage: An opened container of sour cream was found past its use-by date, two opened bags of carrots were stored without open or use-by dates, a tray of individually prepared ice cream cups in the freezer was unlabeled and undated, and an opened container of corn oil was left unlabeled and undated. The DS stated some items did not need dates because they were produce or frozen, but the facility P&P required all foods stored in the refrigerator or freezer to be covered, labeled, and dated.
Advance Directive Not in Resident Chart: A resident admitted with brain disorder, cellulitis, and type 2 DM with diabetic neuropathy had a POLST indicating an Advance Directive, but the Advance Directive Acknowledgement form was incomplete and a copy of the directive was not in the medical chart. The SSD verified the missing documentation, and the DON stated the directive should be in the chart so staff would know the resident's code status and wishes in an emergency.
A resident at risk for pressure ulcers had an LAL mattress ordered for 80 to 150 lbs for wound management and prevention due to a history of a resolved pressure injury, but staff observed the mattress set at Firm for 350 lbs. An LVN confirmed the incorrect setting and an RN/TN stated the mattress should have matched the resident’s weight range, while the facility policy required proper use and maintenance of the mattress per manufacturer guidelines.
Missing Post-Dialysis Assessment and Documentation: A resident with ESRD, HF, and DM was on a dialysis schedule and had a care plan directing staff to document the resident’s return from dialysis and monitor the groin access site. For one dialysis return, the dialysis communication record did not include post-dialysis VS, access site assessment, dressing status, or the resident’s condition, and both the LVN and DON stated the licensed nurse should have completed and documented the post-dialysis assessment.
Insufficient Resident Room Square Footage: The facility failed to provide at least 80 sq. ft. per resident in 14 of 18 resident rooms, all of which were 2-bed rooms with per-resident space ranging from 66 to 73.87 sq. ft. The ADM said the facility wanted to request a room waiver, and observations found the rooms had enough space for beds, bedside tables, wheelchairs, walkers, and resident movement, with no complaints reported by residents, families, or staff.
A resident who was severely cognitively impaired and dependent on staff for all ADLs did not receive required oral care after a meal, as confirmed by observation and staff interviews. The care plan and facility policy specified the need for oral hygiene assistance, but this was not provided by the assigned CNA, resulting in a deficiency in care.
A resident in an LTC facility, admitted with generalized muscle weakness and depression, was not provided an extra blanket despite feeling cold at night. Staff interviews revealed that the process for obtaining additional blankets was ineffective during the night shift, as the Maintenance Supervisor was unavailable, leaving the LVN and CNA unable to fulfill the resident's request. This failure to adhere to the facility's policy on providing a homelike environment led to the deficiency.
The facility failed to deliver mail to residents on Saturdays, affecting six residents who reported receiving mail only from Monday to Friday. The Business Office Manager confirmed that mail was not delivered on Saturdays, and mail received on that day was placed in a locked mailbox until Monday. The Director of Nursing acknowledged the residents' right to timely mail delivery, which was not upheld. The residents had various medical conditions, including cognitive impairments, highlighting the importance of timely mail delivery.
The facility did not post accurate staffing data in an accessible location, as required by policy. The staffing data was placed behind the nurse's station counter, making it difficult to read, and inaccurately showed a resident census of 41 instead of the actual 32. The DSD confirmed the correct number was initially posted but was altered without her knowledge.
The facility failed to accurately complete medical records for three residents, leading to potential delays in treatment. For two residents, the Advance Directives lacked the responsible party's relationship to the resident and the facility representative's title. For another resident, the DON documented care without including the charge nurse's name or title, contrary to facility policy.
The facility did not follow infection control procedures for residents with indwelling catheters, risking MDRO spread. CNAs reused gowns between residents, and an LVN administered G-tube medication without PPE. Staff acknowledged the importance of PPE in preventing infections.
A resident with a full code status was found unresponsive, but the facility failed to announce a Code Blue and delayed CPR initiation. The LVN and CNAs did not follow the facility's emergency procedures, including providing rescue breaths during CPR. The resident could not be revived by paramedics and was pronounced deceased.
A resident with hypertension and a history of falling was administered Amlodipine despite having systolic blood pressure readings below the physician-ordered threshold. This occurred on two occasions, contrary to the facility's medication administration policy, as confirmed by the DON.
A resident's call light system was found to be non-functional, as confirmed by both the resident and a CNA, due to a loose plug. Despite previous repairs noted in the Maintenance Repair Log, the issue persisted, potentially affecting the resident's ability to call for assistance. The resident, who has multiple medical conditions and requires assistance for daily activities, was unable to use the call light to request help.
The facility did not meet the federal requirement of providing at least 80 square feet per resident in fourteen rooms. Despite this, residents and staff reported no issues with space for movement and care. The facility requested a waiver, asserting that the current room sizes do not adversely affect resident care.
A resident with a history of drug abuse experienced a drug overdose due to the facility's failure to provide necessary behavioral health care and services. The facility did not develop a behavior health care plan, provide drug counseling, or conduct surveillance upon the resident's readmission. Additionally, the facility did not perform voluntary inspections of the resident's belongings despite suspicion of illicit drug possession. Staff interviews revealed disbelief in the overdose incident, leading to inadequate actions and security measures.
A resident was readmitted to the facility after treatment for an opioid overdose at a GACH. The discharge orders included Narcan for opioid overdose, but the facility failed to verify and include this medication in the resident's orders upon readmission. The DON admitted to not reviewing each discharge medication order with the physician, resulting in the omission of a critical medication.
A resident with a history of drug abuse and chronic pain syndrome experienced severe pain due to the facility's failure to manage their pain effectively. Despite being prescribed Norco for severe pain, the resident frequently received ineffective Ibuprofen. The facility did not notify the physician about the ineffective pain management, nor did they update the resident's Pain Care Plan. This led the resident to take an unknown medication, resulting in a Fentanyl overdose. Staff interviews revealed a lack of understanding and action regarding the resident's pain management needs.
A resident with COPD, asthma, and hypertension was left unsupervised during a smoke break, contrary to the facility's smoking policy. The staff lacked training on supervision requirements, and there was no updated list of resident smokers, leading to inadequate safety measures.
RN Coverage Not Maintained on Multiple Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) worked 8 consecutive hours seven days a week, including multiple weekends in 10/2025 and 11/2025. A review of the facility’s Direct Care Service Hours Per Patient Day records from 9/2025 to 11/2025 showed no RN on duty for 8 consecutive hours on 10/18/2025, 10/19/2025, 10/26/2025, 11/16/2025, 11/22/2025, and 11/29/2025. The report stated the facility had 30 residents, and the deficiency was identified through record review and interviews. During interviews on 12/3/2025, the DON stated the facility did not require an RN for 8 hours on weekends because it was a small facility and said the facility had been exempted for that reason. She also stated that when she came in for direct care duties, she only signed the Nursing Staffing Assignment and Sign in Sheet, and later stated she was at the facility often and sometimes forgot to sign the sheet. A review of RN and DON timecards, the Nursing Staffing Assignment and Sign in Sheet, and the Department Heads Daily Sign-in Sheet showed no RN or DON coverage for 8 consecutive hours on the listed dates, and on several of those dates there was no DON signature documented. The facility policy titled Departmental Supervision stated the DON is on duty during the day shift Monday through Friday at a minimum and that, in the DON’s absence, a Nurse Supervisor/Charge Nurse is responsible for supervision of nursing activities.
Inaccurate Nurse Staffing Data Posted
Penalty
Summary
The facility failed to ensure that accurate and current nurse staffing data were posted daily at the beginning of each shift for the 11 PM-7 AM, 6:30 AM-3 PM, and 3 PM-11 PM shifts for 30 residents. During an observation on 12/02/2025 at 9:30 AM, an untitled staffing document was posted in the front lobby showing a facility census of 30 and staffing information for RNs, LVNs, and CNAs for each shift, but it did not show the actual time worked on 12/01/2025 for each category and type of nursing staff. During a later observation on 12/02/2025 at 5:00 PM, the same document remained posted without any revisions or updates. On 12/03/2025 at 9:16 AM, the DSD stated the document was a staffing projection prepared by the night shift nurse for the following day and that the facility did not update the posted staffing hours during the day because only projected nursing hours were being posted. On 12/04/2025 at 12:25 PM, the DON stated the facility was only posting projected staffing nursing hours daily in the front lobby and in front of the nursing station, and acknowledged that if actual nursing staffing hours were not posted accurately, residents and visitors would not know the actual number of nursing staff working that day. The facility P&P, revised July 2016, stated that within two hours of the beginning of each shift, the number of licensed nurses and CNAs directly responsible for resident care is to be posted in a prominent location and that the form shall include the actual time worked during that shift for each category and type of nursing staff.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to follow safe and proper food storage practices in accordance with professional standards and its policy and procedure for food receiving and storage. During a concurrent observation and interview in the kitchen, an opened five-pound container of sour cream was found in the refrigerator with a use-by date of 11/30/2025 on the lid, two opened bags of carrots were found in the refrigerator without an opened date or use-by date, a tray of individually prepared ice cream cups was found in the freezer without a label or use-by date and with only a marking of 11/19 on the plastic wrap, and an opened unlabeled and undated one-gallon container of corn oil was found under a kitchen table. The Dietary Supervisor stated the sour cream should be discarded and should not be used. She also stated there was no need for an open or use-by date on the carrots because they were produce and that she knew when they went bad by visual check. For the ice cream cups, she stated there was no need for a use-by date because they were stored frozen. For the corn oil, she stated it should have an open date so staff would know how long to use it and when it would be discarded. The facility policy titled Food receiving and storage stated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated.
Advance Directive Not in Resident Chart
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 3, had an Advance Directive in the medical chart. Resident 3 was admitted with diagnoses that included disorder of the brain, cellulitis of the right lower limb, and type 2 diabetes mellitus with diabetic neuropathy. The resident's H&P dated 8/7/2025 indicated the resident was able to make decisions for activities of daily living. The resident's POLST dated 3/21/2025 indicated the resident had an Advance Directive, but the POLST did not indicate the date of the Advance Directive. The Advance Directive Acknowledgement form dated 8/6/2025 was incomplete and did not indicate whether a copy of Resident 3's Advance Directive was provided to the facility. During a concurrent interview and record review on 12/2/2025, the SSD verified that the form and POLST were not completed and that a copy of the Advance Directive was not in the resident's medical chart. The SSD stated the Advance Directive should be in the chart and noted it was probably in overflow medical records. The DON later stated it was important for the Advance Directive to be in the medical chart so staff would know the resident's code status and requests in an emergency.
Low Air Loss Mattress Set Incorrectly for Resident at Risk for Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to set Resident 14’s alternating pressure/low air loss mattress according to the physician’s order and the manufacturer’s recommendation. Resident 14 was admitted with diagnoses including type 2 diabetes mellitus and muscle weakness, had fluctuating capacity to understand and make decisions, and was assessed as moderately cognitively impaired and at risk for pressure ulcers. The order summary showed an order for a low air loss mattress to be kept between 80 and 150 pounds every shift for wound management, and the care plan also directed the mattress setting to remain at 80 to 150 pounds because of the resident’s history of a resolved pressure injury. During observation, Resident 14 was lying in bed with the head of the bed slightly elevated, and the low air loss mattress was set at Firm for 350 pounds. A licensed vocational nurse confirmed the setting was for a 350-pound resident and stated she did not know the correct setting. The treatment nurse later stated the mattress should always be set according to the resident’s weight range and that Resident 14’s setting should have been between 80 and 150 pounds, but did not know why it was set at 350 pounds. The manufacturer’s guidelines stated the mattress is indicated for prevention and treatment of pressure ulcers when used with a comprehensive pressure ulcer management program, and the facility policy required staff to ensure proper use and maintenance according to manufacturer guidelines.
Missing Post-Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed and documented for one resident receiving dialysis. The resident was admitted with diagnoses including ESRD, heart failure, and diabetes mellitus, and the care plan indicated the resident was on dialysis and should have no complications from treatment. The care plan also directed staff to document the date, time, and condition of the resident when returning from dialysis and to monitor the right groin access site for swelling, pain, bleeding, itching, and signs or symptoms of infection. A physician order indicated the resident was scheduled for dialysis three times per week, and the MDS showed moderately impaired cognition and that the resident had ESRD and was on dialysis. During record review, the resident's dialysis communication record for one dialysis return did not show post-dialysis vital signs, access site assessment, dressing status, or the resident's condition documented. The LVN stated the licensed nurse on duty should have completed the assessment and record after the resident returned from dialysis, and the DON stated licensed nurses must perform and document the post-dialysis assessment in the dialysis communication record.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident area in 14 of 18 resident rooms, including Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16. These rooms were all two-bed capacity rooms, and the reported resident area per person ranged from 66 sq. ft. to 73.87 sq. ft., depending on the room and occupancy. During an interview, the Administrator stated the facility wanted to request a room waiver for the year, and the facility’s letter stated the room sizes caused no negative outcome regarding the health, safety, and welfare of residents. The report states that there were no complaints from residents, families, or staff about room size, and observations from 12/1/2025 to 12/4/2023 found the affected rooms had adequate space, nursing care, comfort, and privacy. Residents in the affected rooms were observed to have enough space to move freely, and each room had beds, bedside tables with drawers, and adequate room for wheelchairs, walkers, or canes. One resident stated there was enough space in the room to move in and out with a wheelchair. The facility policy titled Accommodation of Needs stated the facility would evaluate residents’ unique needs and make environmental accommodations to the extent reasonable.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was severely cognitively impaired and dependent on staff for all activities of daily living, including oral hygiene, did not receive oral care as required. The resident, who had diagnoses including metabolic encephalopathy, dysphagia, and depression, was observed in bed with visible traces of food or milk on the gums after breakfast. The certified nurse assistant (CNA) responsible for the resident confirmed that oral care had not been provided that morning, despite it being her responsibility and an intervention listed in the resident's care plan. Interviews with facility staff, including a licensed vocational nurse (LVN) and the Director of Staff Development (DSD), confirmed that the resident was dependent on staff for oral hygiene and that oral care should have been provided after meals. Review of the facility's policy and procedures indicated that residents unable to perform activities of daily living independently must receive necessary services, including oral hygiene, in accordance with their care plan. The failure to provide oral care as required constituted a deficiency in the facility's provision of necessary care and services.
Failure to Provide Extra Blanket for Resident
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for one of the residents by not supplying an extra blanket when requested. The resident, who was admitted with diagnoses including generalized muscle weakness and depression, reported feeling cold at night and requested an additional blanket on several occasions. However, the staff informed the resident that no blankets were available, leading to feelings of irritation and neglect. Interviews with facility staff revealed a breakdown in the process for obtaining additional blankets during the night shift. The Maintenance Supervisor, responsible for the laundry department, stated that staff should inform him if blankets are unavailable, so he can retrieve one from storage. However, the Licensed Vocational Nurse (LVN) and Certified Nurse Assistant (CNA) indicated that the Maintenance Supervisor is not available during the night shift, leaving them unable to fulfill the resident's request. The facility's policy on providing a homelike environment, which includes supplying extra blankets upon request, was not adhered to, contributing to the deficiency.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their personal mail on Saturdays, affecting six residents. During a Resident Council Meeting, these residents reported that while they received their mail unopened from Monday to Friday, they did not receive any mail on Saturdays. This was confirmed by the Business Office Manager, who stated that mail was only released to the Social Service Director or Activity Assistant during weekdays, and no mail delivery occurred on Saturdays. Observations revealed that mail delivered on Saturdays was placed in a locked mailbox at the nurse station, to be checked by business office staff on Monday. The Director of Nursing acknowledged that it was the residents' right to receive mail timely, indicating a lapse in the facility's adherence to this right. The facility's policy stated that residents should have the right to receive unopened mail and have privacy in their communications, which was not upheld in this instance. The residents involved had various medical conditions, including cognitive impairments and physical disabilities, which could affect their ability to manage their affairs independently. The Minimum Data Set assessments indicated varying levels of cognitive impairment and assistance required for daily activities among the residents. Despite these needs, the facility's failure to deliver mail on Saturdays potentially deprived residents of important and timely correspondence, violating their rights as outlined in the facility's policy.
Inaccurate and Inaccessible Staffing Data Posting
Penalty
Summary
The facility failed to post accurate staffing data in a location easily accessible to residents, their representatives, and visitors. During an observation, it was noted that the staffing data for a specific date was posted on a wall behind the counter of the nurse's station, approximately 10 feet away, making it difficult to read from the countertop. Additionally, the posted staffing data inaccurately reflected the resident census as 41, while the actual census was 32. The Director of Staff Development (DSD) confirmed that she had posted the correct census number of 32 at the beginning of the day shift, but was unaware of who altered the number to 41. The facility's policy requires that staffing numbers be posted in a prominent and accessible location within two hours of each shift's start, which was not adhered to in this instance.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to accurately complete the medical information for three residents, leading to potential delays in treatment and care. For Residents 2 and 25, the facility did not ensure that the responsible party who signed the Advance Directive indicated their relationship to the resident, nor did the facility representative indicate her title on the form. This oversight was confirmed during interviews with the Registered Nurse and the Social Services Director, who acknowledged the missing information and its potential impact on emergency treatment decisions. For Resident 27, the facility did not adhere to its own policy and procedure in documenting the resident's change of condition and nursing notes. The Director of Nursing documented progress notes and a change of condition entry on behalf of a charge nurse without including the charge nurse's name or title, inaccurately reflecting who provided the care. This discrepancy was identified during a review of the resident's records and confirmed by the Director of Nursing, who admitted to documenting the entries as if she had performed the procedures herself. The facility's policy on charting and documentation, revised in 2017, requires complete and accurate documentation, including the name and title of the individual providing care. The failure to follow this policy for Resident 27, along with the incomplete Advance Directives for Residents 2 and 25, highlights deficiencies in maintaining accurate medical records and safeguarding resident-identifiable information.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures for three residents who were at risk for Multi-Drug Resistant Organisms (MDRO) due to having indwelling catheters. During observations, Certified Nursing Assistants (CNAs) were seen not following Enhanced Barrier Precautions (EBP) as they did not change isolation gowns between caring for different residents. Specifically, CNA 1 and CNA 2 were observed wearing the same gown while attending to Resident 16 and then Resident 11, despite the clear signage indicating the need to change gowns to prevent infection spread. Both CNAs acknowledged their failure to change gowns, recognizing the importance of this practice in infection prevention. Additionally, a Licensed Vocational Nurse (LVN) was observed administering medication via a Gastrostomy-Tube (G-tube) to Resident 19 without wearing an isolation gown, which is crucial due to the high risk of exposure to bodily fluids. The LVN admitted to not donning the required PPE, understanding its significance in preventing infection transmission. The Infection Preventionist (IP) Nurse confirmed that the expectation was for all staff to wear appropriate PPE, such as gowns, during such procedures to minimize the risk of MDRO transmission, in line with CDC guidelines.
Failure to Implement Emergency Protocols During Medical Emergency
Penalty
Summary
The facility failed to adhere to professional standards of practice and its own policies during a medical emergency involving a resident. The resident, who had a history of diabetes mellitus, hypertension, and falls, was found unresponsive by a Certified Nursing Assistant (CNA). Despite the resident's Physician Orders for Life Sustaining Treatment (POLST) indicating full code status, Cardiopulmonary Resuscitation (CPR) was not initiated immediately. The Licensed Vocational Nurse (LVN) delayed CPR while verifying the resident's code status, which was a critical lapse in emergency response. The facility's paging system was not used to announce a Code Blue, which is a breach of the facility's emergency management procedures. This failure to alert other staff members potentially delayed the provision of necessary assistance. The LVN and CNAs involved did not follow the facility's policy of providing rescue breaths after 30 chest compressions during CPR, further compromising the emergency response. Interviews with staff revealed confusion and lack of adherence to the facility's emergency procedures. The LVN did not remember if a Code Blue was called and did not consistently perform CPR according to the facility's policy. The Director of Nursing (DON) and Director of Staff Development (DSD) confirmed that the staff should have paged Code Blue and initiated CPR immediately. The paramedics were unable to revive the resident, who was pronounced deceased shortly after their arrival.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to its pharmaceutical services policy by administering Amlodipine to a resident when their systolic blood pressure was below the parameters set by the physician's order. The resident, who was admitted with diagnoses including diabetes mellitus, hypertension, and a history of falling, was given Amlodipine despite having systolic blood pressure readings ranging from 102 mm Hg to 108 mm Hg, which were below the threshold of 110 mm Hg specified in the physician's order. This occurred on two occasions, as documented in the Medication Administration Record for October 2024. The Director of Nursing confirmed during an interview that the medication should not have been administered under these conditions, as per the physician's order. The facility's policy on administering medications, revised in April 2019, mandates that medications must be administered in accordance with the physician's orders. The resident's Minimum Data Set indicated severely impaired cognitive skills, requiring supervision to extensive assistance for daily activities, which underscores the importance of adhering to prescribed medication protocols.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that the call light system was in good functioning condition for one of the residents, identified as Resident 23. During an observation and interview, Resident 23 demonstrated that the call light system was not working, as pressing the button did not produce an audible sound or activate the light above the door. A Certified Nursing Assistant (CNA) confirmed the malfunction and attributed it to a loose plug on the wall, stating that she would report the issue to the charge nurse and maintenance. The Maintenance Repair Log Sheet indicated that the call light had previously been reported as having no sound and was repaired on a prior date, but the issue persisted. Resident 23, who has multiple medical conditions including contractures, muscle weakness, and cognitive impairments, requires assistance for various activities of daily living. The facility's policies and procedures emphasize the importance of maintaining equipment, including call lights, in a safe and operable manner. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Maintenance Supervisor, highlighted the expectation that call lights should be functioning to ensure residents can call for help, and that maintenance should address any issues promptly. Despite these policies, the call light in Resident 23's room was not functioning properly, posing a risk to the resident's ability to call for assistance when needed.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in fourteen out of sixteen resident rooms. During an entrance conference, the Administrator acknowledged that these rooms did not meet the federal regulation set by the Centers for Medicare & Medicaid Services (CMS). The rooms in question were observed to have less than the required space, with some rooms providing as little as 59.96 square feet per resident. Despite this, observations and interviews with residents and staff indicated that they did not express concerns about the room sizes, and staff reported being able to perform necessary tasks without issues. The facility submitted a request for a room waiver, indicating that the approval of the waiver would not adversely affect the health, safety, and welfare of the residents. The waiver request included specific measurements of the rooms, all of which were below the required 80 square feet per resident. The facility argued that the waiver was in accordance with meeting the special needs of each resident, suggesting that the current room sizes were adequate for providing privacy, comfort, and nursing care.
Failure to Provide Behavioral Health Care for Resident with Drug Abuse History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of drug abuse, leading to a drug overdose incident. The resident, who had a history of opiate and fentanyl overdose, was readmitted to the facility from a general acute care hospital. However, the facility did not develop or implement a behavior health care plan to address the resident's substance abuse needs. This included failing to provide drug counseling and surveillance, as well as not assessing and identifying the resident's behavioral needs for drug counseling and surveillance upon readmission. The facility also did not attempt to perform voluntary inspections of the resident's belongings, despite having reasonable suspicion of possession of illicit drugs. This oversight occurred after the resident was transferred to the hospital for an opiate/fentanyl overdose. The facility's policies and procedures for managing illicit drug use and conducting behavioral assessments were not followed, contributing to the resident's exposure to illicit drug use and subsequent overdose. Interviews and record reviews revealed that the facility's staff, including the Director of Nursing and Social Services Director, did not believe the resident's overdose was real and therefore did not take appropriate actions to address the situation. The facility's security measures were inadequate, as the security guard did not intervene when the resident received a pill from a friend outside the facility gate. The lack of a comprehensive care plan and failure to monitor the resident's condition and belongings contributed to the deficiency.
Removal Plan
- The facility reviewed and developed a behavior care plan for drug abuse for Resident 1's past history of drug abuse. The facility conducted an Interdisciplinary Team meeting with Resident 1 regarding any drug use.
- The ADM conducted an investigation to determine the possibilities on how the incident could have happened. Based on ADM investigation, closer supervision could be needed by the gate.
- The facility Security guards was immediately given in-service to be in close proximity to the gate. The Security Guard was placed at the facility gate. Security Guards' shifts are 7 AM to 3 PM and 3 PM to 11 PM, seven days a week. Security Guards will screen everyone they encounter, with an emphasis on looking for suspicious behavior and drug contraband from all persons, including staff, residents and visitors. Security Guards will document all person interactions with time, date, and name. Security Guards will report abnormal findings to nursing supervisor.
- Staff will also have the responsibility for facility wide supervision and was in-serviced specifically for Fentanyl, regarding how to spot signs of active, potential usage and its physical form by the Director of Staff Development. 48 staff out of 54 staff informed with an expected completion date.
- ADM called the police to report the incident. In the ADM or DON's absence, the nursing supervisor can inform the police of any illicit activity.
- The IDT reviewed all residents' charts to determine if there are other residents that have history of drug abuse, two residents found. The facility updated their behavior care plans to ensure their needs are met and completed.
- History of drug abuse created and placed at the Nursing Station with contents identifying all current residents that have a history of drug abuse, for staff reference. Staff informed regarding newly identified residents.
- Developed an individualized intervention for Resident 1, which included scheduling of counseling from the facility Psychologist, with a focus on opiate and fentanyl overdose and drug abuse. The Psychologist will visit Resident 1, two times a month.
- Upon readmission, Resident 1 will be interviewed by Social Services, questions will include an emphasis on history of illicit drug abuse.
- All nursing staff will review residents' records to establish if there is a history of drug abuse/use, care plans will be implemented for residents that are found to have a history of drug abuse.
- Resident belongings will also be thoroughly checked (with the resident's permission) to ensure no contraband is present and brought into the facility.
- Residents suspected of illicit drug usage (Fentanyl) will be drug tested in according to the facility's Illicit drug policy. Residents have the right to refuse drug testing as it is voluntary.
- For ongoing suspicion of illicit drug use of residents, the IDT team will conduct and IDT meeting informing the resident of the facility policy, including that all drug testing is voluntary.
- The facility staff conducted a search in Resident 1's room with the resident's consent. This search was repeated, no contraband found. The facility also conducted a whole facility search and no contraband was found. The facility will conduct weekly contraband searches every 4 weeks and them monthly for the next 6 months.
- Resident 1 was prescribed Norco every eight hours as needed for pain management. This is to prevent Resident 1 from seeking pain relief through illicit means.
Failure to Verify Discharge Orders Leads to Medication Omission
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the facility's policy and procedure during the resident's readmission. Specifically, the facility did not verify all appropriate discharge orders from the General Acute Care Hospital (GACH) with the attending physician upon the resident's readmission. This oversight included the failure to order Narcan, a medication necessary for treating opioid overdose, as indicated in the discharge orders from GACH. The resident, who had a history of flaccid hemiplegia and chronic obstructive pulmonary disease, was readmitted to the facility after being treated at GACH for an opioid overdose. The GACH records indicated that the resident had been found unresponsive with symptoms consistent with an opioid overdose and had been treated with Narcan, which improved their condition. The discharge orders from GACH included a prescription for Narcan to be administered as needed for opioid overdose, but this was not included in the resident's medication orders upon readmission to the facility. During an interview, the Director of Nursing (DON) acknowledged that there was no documented evidence of the Narcan order being included in the resident's medication regimen upon readmission. The DON, who was also the admitting nurse, admitted to not reviewing each discharge medication order individually with the resident's physician. This failure to reconcile the medication orders as per the facility's policy and procedure led to the omission of a critical medication necessary for the resident's immediate care.
Failure in Pain Management Leads to Resident Overdose
Penalty
Summary
The facility failed to manage a resident's pain timely and effectively, leading to a significant deficiency in care. The resident, who had a history of drug abuse and chronic pain syndrome, was prescribed Norco for severe pain following an evaluation at a General Acute Care Hospital (GACH). However, the facility did not ensure the timely receipt and administration of this medication. Instead, the resident was frequently given Ibuprofen, which was ineffective for their level of pain. The facility also failed to notify the physician about the ineffectiveness of the pain management regimen and did not update the resident's Pain Care Plan to include specific interventions for pain relief. The resident experienced severe pain, with a pain level of 8 on the pain scale, and was sent to the hospital for further evaluation. Despite the resident's complaints and the ineffectiveness of non-pharmacological interventions, the facility did not reassess or modify the pain management approach. The resident eventually took an unknown medication, leading to an overdose of Fentanyl, which required emergency medical intervention. The facility's lack of documentation and communication with the pharmacy and physician contributed to the delay in providing appropriate pain medication. Interviews with facility staff revealed a lack of understanding and action regarding the resident's pain management needs. The Licensed Vocational Nurse (LVN) admitted to not knowing when to refer a resident for a pain evaluation, and the Registered Nurse Supervisor (RNS) failed to confirm the receipt of the Norco order with the pharmacy. The Director of Nursing (DON) acknowledged that the facility did not document the characteristics and pattern of the resident's pain, which was crucial for validating the effectiveness of the medication and adjusting interventions as needed.
Failure to Supervise Resident During Smoke Break
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding smoking supervision, which resulted in a deficiency. Specifically, the facility did not provide staff supervision for a resident during a scheduled smoke break. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, asthma, and hypertension, was identified as requiring supervision during smoking times according to their Smoking Safety Evaluation and Care Plan. However, on the observed date, the resident was left unsupervised while smoking, contrary to the facility's policy. The deficiency was further compounded by a lack of in-service training for facility staff regarding the smoking policy and care plans for residents who smoke. Security personnel responsible for supervising smoke breaks were not adequately informed or trained on the specific supervision needs of each resident. This lack of training and communication led to a situation where the security guard left the resident unsupervised, not knowing the supervision requirements or the need for safety measures such as smoking aprons. Additionally, the facility did not maintain an updated list of resident smokers, which is crucial for ensuring proper supervision and safety measures are in place. The Activities Assistant was not provided with a list of residents who smoke, and there was a discrepancy in communication between the Social Services Director and the Activities Assistant regarding the residents who required supervision during smoke breaks. This lack of coordination and adherence to the smoking policy put the resident and potentially others at risk during unsupervised smoking sessions.
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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 Pacific Care Center | 0.6 mi | ★★★★★ | 21 | 0 |
| Presbyterian Intercomm Hosp Dp/snf | 1.2 mi | ★★★★★ | 0 | 0 |
| The Orchard - Post Acute Care | 1.2 mi | ★★★★★ | 26 | 0 |
| Whittier Hospital Medical Ctr D/p Snf | 1.8 mi | ★★★★★ | 1 | 0 |
| Socal Post-acute Care | 2.4 mi | ★★★★★ | 22 | 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 June 2026) and official state health department websites.