Whittier Nursing and Wellness Center, Inc

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours seven days a week in the facility including the following weekends: 10/18/2025, 10/19/2025, 10/25/2025 10/26/2025, 11/16/2025/ 11/22/2025, and 11/29/2025 that care for 30 or 30 residents in the facility. This deficient practice had the potential for the residents' care not to be supervised and assessed clinically by the RN which could affect the quality of care and quality of life of the residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 6:30 AM - 3 PM, and 3 PM - 11 PM) to care for 30 residents of 30 residents. These deficient practices of posting inaccurate and outdated nurse staffing data had the potential to mislead and prevent residents and families from verifying the facility's daily staffing levels. This could result in distrust and a perceived lack of accountability in maintaining accurate and adequate staffing necessary for timely resident care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label and date food items and discard expired food inside the facility's kitchen. This failure had the potential to cause food-borne illness (illness caused by the ingestion of contaminated food or beverages) and adversely affect the health of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) reviewed for resident's rights did not have Advance Directive (a legal document for stating medical wishes if one was unable to communicate) in resident's medical chart. 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 interview, observation and record review, the facility failed to set the Alternating Pressure Mattress (APM, mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation and physicians orders for one of one sampled residents (Resident 14) reviewed for pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction). Resident 14's mattress was observed set for 350 pounds (lbs.) while the resident weights 99lbs. This deficient practice had the potential for Resident 14 to develop worsened or new pressure ulcer or injury and/or delay the resident's wound to heal.

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment was completed and documented after dialysis (a treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) for one of one sampled resident (Resident 7) reviewed for quality of care. This failure had the potential to put Resident 1 at risk for hypotension (low blood pressure [BP- the force of your blood pushing against your artery walls, like water in a hose]), bleeding, and access site (area on the body where the dialysis machine hooks up to the blood for dialysis) complications leading to hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for fourteen (14) out of eighteen (18) resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16). The 14 resident rooms consisted of 14 -two (2) bed capacity rooms. This deficient practice had the potential to impact the ability of the staff to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs), received services to maintain good oral hygiene as indicated in the care plan by the certified nurse assistant (CNA) 1 after Resident 1 had been assisted and finished with his meal. This deficient practice had the potential to place Resident 1 at risk for diseases of the mouth, gums, and teeth, and aspiration (something other than air gets into your airways) of the food pieces in the mouth could further lead to pneumonia (an infection/inflammation in the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment to one of thirteen sampled residents (Resident 2) by failing to provide the resident an extra blanket when the resident was cold at night. This deficient practice had the potential to expose the resident to an increased risk of hypothermia, discomfort, chills, worsening of existing medical conditions, and potential for skin breakdown from cold exposure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of 6 sampled residents (Resident 28, 20, 21, 2, 5, and 81), received personal mails when delivered on Saturdays at the facility. This failure resulted in violating Resident 28, Resident 20, Resident 21, Resident 2, Resident 5, and Resident 81 rights to received mail on Saturdays which could result of missing important and timely correspondence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post an accurate facility staffing data in a prominent place where 32 of 32 residents and their representaives and visitors could easily view. This deficient practice had the potential to compromise the quality of care the residents receive due to potential insufficient staffing in the facility.

Inspectors wrote2. During a review of Resident 27 ' s admission Record (Face Sheet), dated 10/23/2021, the face sheet indicated the facility admitted Resident 27 on 10/14/2024 with diagnoses including diabetes mellitus (elevated sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and history of falling. During a review of Resident 27 ' s History and Physical (H&P), dated 10/16/2024 indicated, Resident 27 had the mental capacity to make medical decisions. During a review of Resident 27's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/20/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility ' s infection control policy and procedure for three of 3 sampled residents (Resident 11, 16, and 19) by failing to: Ensure that Enhanced Barrier Precautions (EBP-a set of infection control measures that use personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs) were implemented by Certified Nursing Assistant (CNA 1, and 2 ) for three of 3 sampled Residents (Resident 11, 16, and 19) who all have indwelling catheter (a medical device that remains inside the body and provides a direct path for pathogens [any organism that causes disease] to enter the body and cause infection) and were at risk for Multi-Drug Resistant Organisms (MDRO, disease causing organism that have become resistant to certain antibiotics). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the professional standard of practice and the facility ' s policy and procedure titled Emergency Management Codes and Procedures for medical emergency (Code Blue- is a hospital code to alert the facility staffs of a medical emergency) by failing to ensure: 1. Call Code Blue was announced on the facility ' s paging system when Resident 27 was found unresponsive to verbal stimuli and responsive to painful stimuli with decreased heart rate, respiratory rate, and blood pressure (the measurement of the pressure in the blood vessels when the heart relaxes or contracts the force of blood pushing against artery walls as the heart pumps blood throughout the body). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services as indicated in the facility's policy and procedure title Administering Medications for one of 3 sampled residents (Resident 27), who was administered Amlodipine (medication used to treat high blood pressure) when the resident ' s blood pressure was below the parameters (a fixed limit) set by the physician's order. These deficient practices had the potential to result in unintended complications such as dizziness, drowsiness, syncope (loss of consciousness) due hypotension (abnormally low blood pressure) that could lead to falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was in good functioning condition for one of sixteen sampled residents (Resident 23). This failure had the potential for Resident 23 not being able to call for assistance especially during emergency that could result in fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for fourteen (14) out of sixteen (16) resident rooms (room [ROOM NUMBER],2,3,4,5,6,7,8,10,12,13,15 and 16). This deficient practice had the potential to negatively impact the quality-of-care and the ability of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary services (drug counseling and surveillance [monitoring of behavior; activities]) and develop person centered care plans for the behavioral healthcare needs for substance abuse for one of three sampled residents (Resident 1), who had a history of drug abuse (the excessive or addictive use of drugs for nonmedical purposes) and prevent Resident 1 from experiencing a drug overdose (an excessive and dangerous dose of a drug) of opiate (a controlled drug used to treat pain or cause sleep) and fentanyl (a powerful, controlled drug that is used to treat severe pain) while residing in the facility by failing to: 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility ' s policy and procedure [P&P] titled admission Assessment and Follow Up: Role of the Nurse, for one of two sampled residents (Resident 1) when it failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 3 were verified with the attending physician (Physician 1) upon Resident 1 ' s readmission to the facility on [DATE]. This deficient practice could result in Resident 1 not receiving emergency medications such as Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) needed to treat opioid overdose.

Inspectors wroteBased on observation, interview, and record review the facility failed to manage a resident ' s pain timely and effectively for one of two sampled residents (Resident 1), in accordance with the facility ' s policy and procedure titled Pain Assessment and Management, by failing to: 1. Follow the General Acute Care Hospital (GACH) 1 recommendations on pain management and the physician ' s order for Norco as needed for severe pain dated 9/9/2024. 2. Follow up with the pharmacy to ensure the ordered pain medication [Norco] was received and delivered timely. 3. Notify the physician when Resident 1 ' s pain management regimen was ineffective, and the resident received pain medication for mild pain [Ibuprofen], almost daily. 4. Update Resident 1 ' s Pain Care Plan to reflect specific resident-centered interventions needed to relieve the resident ' s pain. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility ' s policy and procedure (P&P) titled Smoking Schedule to ensure staff supervision during smoke breaks was implemented to provide safety for each resident during smoking, for one of three sampled residents (Resident 2) by failing to: Provide Staff supervision for Resident 2 during the facility ' s smoke break on 9/18/2024. Provide in-service to facility staff about the facility ' s Smoking P&P and smoking care plan for each resident who smokes. Ensure the facility maintained an updated list of resident smokers for reference. This deficient practice had the potential for Resident 2 and other resident smokers to be at risk for injury or burns without proper supervision and for the facility staff supervising not having the knowledge of what type of supervision are needed for each resident smoker.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat two of 2 residents (Resident 20 and 83) with respect, privacy and dignity by failing to ensure: 1. Resident 20's nephrostomy bag (a small flexible, rubber tube that is placed through your skin into the kidney to drain your urine) was covered to provide privacy. 2. Resident 83's privacy curtain was drawn close to provide privacy to the resident while Certified Nursing Assistant 1 (CNA 1) rendered care to Resident 83. These deficient practices had the potential to cause a 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 provide reasonable accommodation of need for three of three sampled resident (Resident 9, 6 and 20) who was at risk for fall, by failing to ensure the residents call light (a device attached to the wall used by residents to call for assistance from the staffs) was within reach as indicated in the facility's policy and procedure, titled Answering the Call Light and resident's Care Plan. This deficient practice had the potential for the resident not to receive or received delayed care to meet the necessary care and services that could result in fall and accident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three (3) opened bottles of Enulose (also known as Lactulose-medication used to treat chronic constipation) solution stored in the medication cart which belonged to 3 of 3 residents (Resident 9, 8, and 21) were marked with the date that the bottles were first opened in accordance to the facility's policy and procedure for medication storage. This deficient practice had the potential to result in the loss of efficacy of medication due to unsafe storage of the medications.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow the facility's policy and procedure titled Confidentiality of Information and Personal Privacy by ensuring the resident's identifiable, personal and medical information were not exposed on the computer screens and left unattended while in view of unauthorized persons and access two out of 2 residents (Resident 16 and 17) confidential information without the resident's consent or knowledge. This deficient practice resulted in Resident 16 and 17's violation of resident's right for privacy to keep their personal and medical records confidential and not readily observable and accessible by others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary environment to prevent the development and transmission of infections by ensuring the oxygen tubing or Nasal Cannula (NC-a device with two prongs inserted below the nose used to deliver supplemental oxygen directly into the nostrils or nares [opening of the nose]) was kept clean to prevent contact with disease causing organisms for for two of two residents (Resident 20 and 137) as indicated in the facility's policy and procedure by failing to ensure: 1. Resident 20's NC tube was not touching the floor. 2. Resident 137's NC was not touching the humidifier bottle (a bottle connected to the oxygen machine that moisturizes the air in the NC before breathing in the air) when not in use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor, inform the physician and provide necessary care and services in accordance with the facility's policy and procedure titled, Anticoagulation (medication for blood thinner) - Clinical Protocol and the resident's care plan for one (1) of one sampled resident (Resident 82), who was observed with bruises (skin discoloration due to bleeding underneath) while receiving Aspirin (a medication used to treat pain and reduce formation of blood clots). This deficient practice resulted in Resident 82's development of new bruises and skin tear that was undetected which could result in blood loss, infection and other side effects (unwanted effects of medication) and a decline in the resident's well being.

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of medication for one of one sampled resident (Resident 24) who was not monitored for bruising and bleeding while receiving Aspirin (acetylsalicylic acid [ASA], a medication used to treat pain and reduce formation of blood clots). This deficient practice increased the risk of Resident 48 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as bleeding and bruising in the intestines and stomach, other parts of the body.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for fourteen (14) out of eighteen (18) resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16). The 14 resident rooms consisted of 14 -two (2) bed capacity rooms. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.