Whittier Hospital Medical Ctr D/P SNF

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper food storage and infection control practices were implemented in accordance with the facility's Policy and Procedure (P&P) titled Standards for storing food and supplies, and Infection Control - Food and Nutrition Services by failing to: 1. Ensure thermometers were kept inside refrigerators 1 and 2. 2. Ensure a pitcher of pre-made iced tea was not left in the refrigerator beyond safe use by date of 6/8/2026. 3. Ensure Dishwasher (DW) 2 used the correct test strip to test for the quaternary ammonium (QUAT-a quaternary ammonium, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer. 4. Ensure dishwashing machine temperature was checked for PM shift on 6/8/2026 and ensure the dishwashing machine thermometer is working appropriately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide privacy for one of one sampled resident (Resident 1) reviewed for dignity when Resident 1's nephrostomy bag (a clear bag thatcollects your pee (urine) from your kidney) was exposed. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline, resident's individuality, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of five (3) sampled residents' (Resident 21) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 21 had a specific, measurable target behavior related to the use of Sertraline (an antidepressant medicine used to treat depression [a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities]). 2. Resident 21 was monitored for the number of specific occurrences of behavior that was associated with the use of Sertraline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of three (3) sampled residents (Residents 16) observed for medication administration by failing to: Administer Resident 16's Miralax (a medication used to treat chronic constipation) with 4-8 ounces of water as ordered by the physician. Administer all of Resident 16's multivitamin This deficient practice resulted in Resident 16 not receiving medications as ordered by the physician, which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to report to the physician irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) and to address the use of Sertraline (an antidepressant medicine used to treat depression [a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities] and other mental health conditions) on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of five residents [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 8 % for one (1) of three (3) sampled residents (Resident 16) observed during medication administration (med pass). This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of Resident 16's condition, or potentially serious harm or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten dishwashers were competent in their duties when Dishwasher 2 (DW 2) did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT-a quaternary ammonium, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer and when DW 2 did not know the procedure for testing strength of the quaternary ammonium sanitizer. This deficient practice had the potential to result in unsafe and unsanitary food production and could affect residents who were served food from the facility kitchen. During a concurrent kitchen tour and interview on 6/9/2026 at 10:23 AM with the Director of Food and Nutrition Services (DFN), two sink areas were observed. [...]

Inspectors wroteBased on interview and record review, the facility's failed to meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, and ensure the required committee members (Thedirector of nursing (DON), The Medical Director or his/her designee, The Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member) were inregular attendance of the facilities quality assessment and assurance (QAA) meetings. This deficient practice had the potential to affect all of the facilities 22 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to review the infection prevention and control program (IPCP) annually in accordance with the facility's policies and procedures (P&P) titled, Pediatric Subacute Infection Prevention Program 2024-2025. The deficient practice had a potential for the IPCP to fail in ensuring quality and compliance with recommended guidelines and practices. During an interview on 6/10/2026 at 1:25 PM with the Infection Prevention Nurse (IPN), the IPN stated, the facility's infection control policies and procedures are reviewed every three (3) years. The IPN stated she could not remember the last time she reviewed the facility's infection prevention and control program (IPCP). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff adhere to the facility's infection control program in accordance to its policy and procedure when three of three sampled residents were found to have a positive rhinovirus (a common cause of the common cold) result within a four day period. This deficient practice had the potential to result in putting residents and staff at risk for more transmissions of infections within the facility. During a record review of Resident 1's History and Physical (H&P), dated 09/02/2025, the H&P indicated Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed for two (2) of three (3) sampled residents (Resident 2 and Resident 11) was maintained at 30 to 45 degrees (unit of measurement) while receiving gastrostomy tube (g-tube, a small tube inserted through a surgical opening in the abdomen directly into the stomach used to deliver nutrition, fluids, and medications to individuals who cannot eat or drink safely through their mouth) feeding, in accordance with the physician's order and facility's policy and procedure. This deficient practice had the potential to cause complications including aspiration (a medical sense, occurs when food, liquid, or foreign objects enter the airway and lungs) that can lead to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean, sanitary, and functional manner while providing proper food handling in accordance with the facility's policy and procedure by failing to ensure: 1. One refrigerator (Refrigerator #10) was clean, without water drippings, and was not rusted (a form of corrosion visible on steel surfaces exposed to moist). 2. One can opener was not chipped and rusted. 3. The food processor was in good condition and without a brown, black to yellowish discoloration and calcium build ups (hard crusty deposit on surfaces and/ equipment). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to observe infection control measures for one of four sampled residents (Resident 13) by failing to ensure that the Staff 1 washed hands after touching the floor while picking up the table napkin and continued to assist on feeding Resident 13. This deficient practice had the potential to transmit infectious microorganisms (microbes that are temporarily harbored on the superficial surface of the body) and increase the risk of infection for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable, sanitary and environment by: 1. Facility failed to ensure three (3) of six (6) restroom sinks (rooms [ROOM NUMBER]) have no yellowish, brownish, and chipped sideboard. 2. Facility failed to ensure the table in activity classroom was in good condition and did not have edges that were peeling off, exposing the wood part of the table and chipped off leaving sharp and rough edges 3. Facility failed to ensure the trash can in room [ROOM NUMBER] was not overflowing. These deficient practices caused an unsanitary and had potential for residents to be placed at risk of injury and/ or infection.

Inspectors wrote2. During a review of Resident 11's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE] with congenital ( a condition or trait that exists at birth) hypoplasia and dysplasia of lung (condition where the baby's lungs have not fully developed) , chronic respiratory disease (diseases that affect the lungs and airways), encounter for attention to gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 11's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 11 was dependent on transfers (how resident moves to and from bed, chair and wheelchair), eating, dressing, and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 17) in accordance with the facility policy by failing to administer Resident 17's 8 AM due medications on 4/25/2025 as indicated on the physician's order. This deficient practice had the potential for Resident 17 to experience tachycardia (a fast heartbeat of more than 100 times per minute), high blood pressure (when your blood pressure is consistently higher than normal), pain and decline in overall health status.

Inspectors wroteCross reference: F755 Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Seven (7) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 30 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 23.33 % for one (1) of four (4) sampled residents (Resident 17) observed during medication administration (med pass). Resident 17's scheduled 8 AM medications were not administered timely as indicated on the physician's order and facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four resident's skin integrity was assessed and treated by wound care services when consulted by nursing staff in accordance with the facility's policy and procedure. This failure resulted in Resident 1's persistent redness to the chest area for five days, which did not get assessed and treated by wound care services, which compromised Resident 1's health and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure two (2) of 4 sampled residents (Residents 15 and 19) had a completed advanced directive acknowledgment form (a form indicating to the resident or responsible party the right to give written directions about future treatment before becoming seriously ill or unable to make healthcare decisions). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate care to four of four sampled residents (Resident 4, 9, 11, and 12) who had a gastrostomy tube (G-Tube, a tube placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications) by failing to: 1. Ensure the tube feeding syringe was labeled with date opened for Resident 4, 9, 11, and 12. 2. Ensure a new bottle of Peptide-Based Nutrition ( nutritional formula) was used for Resident 4, feeding was used for more than 24 hours. These deficient practices placed Resident 4, 9, 11, and 12's G-tube at risk for getting clogged and contaminated which had the potential to cause discomfort and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Attending Physician (AP) reviewed the drug regimen thoroughly and documented in the resident's medical record if the identified irregularities and recommendation of the pharmacyst were accepted, rejected and a rationale was documented if the Pharmacist recommendations in the Medication Regimen Review (MRR)were accepted or rejected for four of four sampled residents (Resident 3, 5, 9, and 10). This deficient practice had the potential for the residents to receive excessive or insufficent dosage of medications that the could harm the residents and/or not receive the right medication to treat the resident's underlying medical condition due to the missed opportunity to act upon the reported irregularities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage, labeling of food, and preparation practices in the kitchen, in accordance with the facility's policy and procedures on Cleaning Schedule Use and Cleaning of Equipment. 1. One opened unlabeled plastic container with a single ice cream cone was found in the freezer. 2. Food particles found inside the freezer floor. 3. A bundle of wilted black colored cilantro (leafy vegetable) and molded jicama (fruit) were found in the refrigerator. 4. Open, unlabeled and undated personal beverage cup found in the kitchen food prep area. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wrote3. A review of Resident 13 ' s admission record indicated an admission to the facility on 1/1/2024, with a diagnosis of Di [NAME] ' s syndrome (a chromosomal or form of genetic disorder that results in poor development of several body systems). A review of Resident 13 ' s MDS dated [DATE], indicated Resident 13 had diagnoses that included seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.), asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During an observation on 4/12/2024 at 12:30 PM, the facility ' s unit entrance signage was observed indicating N95 mask must be worn in all patient care areas. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes and interventions for one of two sampled resident's (Resident 15) with urinary catheter (a device that drains urine from the urinary bladder into a collection bag). This deficient practice had the potential for Resident 15 not to receive appropriate care, treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 13): 1. Resident 13's aerosol, oxygen system(a medical device is used to convert the medication into fine aerosol particles which can be inhaled or propelled directly into the airway and lungs) was dated with the date it was changed, in accordance with the facility ' s policy and procedure on Respiratory Equipment Handling. 2. Resident 1's tracheostomy mask (a soft plastic mask that fits over the trachea opening) was stored in a plastic bag when not in use, for infection control. This deficient practice placed the Resident 13's respiratory equipment at risk for contamination and Resident 13 at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality for 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknown length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknow length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back.