Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Socal Post-acute Care during CMS and state inspections, most recent first.
Two residents who had undergone orthopedic surgery did not receive proper care during transfers due to CNAs lacking competency and knowledge of required precautions. One resident suffered a new fracture after staff failed to follow transfer instructions, while another had physician orders disregarded regarding positioning. Staff interviews and record reviews revealed that CNAs had not been assessed for competency in transferring residents with recent orthopedic procedures, and facility policies requiring individualized transfer methods and demonstrated competencies were not followed.
Two residents experienced deficiencies in medication management, including a missing bubble pack of Dilaudid for a resident with amputations and neuropathy, and improper administration and documentation of Alprazolam for a resident with dementia. Staff failed to consistently verify medication quantities and document administration as required, leading to discrepancies between medication records and actual counts.
A resident with dementia and osteoarthritis experienced a fall and reported ankle pain, leading to a physician-ordered x-ray. The facility failed to follow up with the radiology company to obtain the x-ray results, resulting in a delay of several days before the fracture was identified and the physician was notified. Multiple nurses did not communicate or escalate the missing report, and the DON was unaware of the issue until after the delay, contrary to facility policy requiring timely notification of changes in condition and test results.
The facility failed to manage its trash disposal, resulting in an overflowing trash bin and scattered trash in the parking lot, visible from residents' windows. The Dietary Director and Maintenance Director acknowledged the issue, noting that trash should be in the container to prevent attracting pests. The Director of Nursing reviewed the facility's policy, emphasizing the need for a clean and homelike environment.
The facility failed to label an open pack of ground beef in the freezer with an opening date, as required by its policy. The Dietary Director acknowledged the oversight, noting the potential risk of food-borne illnesses if residents consume the unlabeled meat. The DON emphasized the importance of labeling to prevent serving expired food, which could lead to health issues for the 54 residents receiving meals from the facility's kitchen.
A resident's Advance Directive Acknowledgment Form was not completed upon admission, despite the resident's inability to make decisions due to medical conditions. The Social Services Designee confirmed the oversight, which could lead to misinformation about the resident's medical care and treatment preferences.
A facility failed to ensure a resident with diabetes received appropriate care upon readmission from a hospital. The resident did not receive necessary insulin and blood sugar monitoring due to a lack of verification of discharge orders with the attending physician. The Director of Nursing confirmed the absence of orders, and interviews revealed that the admitting nurse did not verify the continuation of insulin orders, despite the resident's history of diabetes management.
A facility failed to ensure the accuracy of the MDS for a resident with diabetes mellitus, leading to the absence of physician orders for diabetes management. Despite the resident's MDS indicating an active diagnosis of diabetes and insulin administration, there were no current orders for diabetic management upon readmission. The DON confirmed the lack of orders and the MDSN admitted to miscoding the MDS, highlighting a failure to accurately assess the resident's status.
A facility failed to update a resident's care plan for diabetes management upon readmission, resulting in the absence of physician orders for insulin and blood sugar checks. Despite having a history of diabetes mellitus, the care plan was not revised to reflect current orders, potentially impacting the resident's treatment. The DON confirmed the oversight, highlighting the need for clarification with the physician to ensure proper diabetes management.
A facility failed to conduct a comprehensive nutritional assessment for a resident with diabetes mellitus, leading to the absence of appropriate dietary orders upon readmission. The resident, who had been receiving insulin prior to readmission, did not have orders for diabetic management, which the DON confirmed could result in uncontrolled blood sugar levels. The CD missed the diabetes diagnosis during the nutritional assessment, leading to an incorrect diet being prescribed.
A resident with chronic respiratory failure was not receiving the correct oxygen flow rate as ordered by their physician. The resident's oxygen machine was set at 4.5 LPM, exceeding the prescribed 2 to 4 LPM range. This was confirmed by an LVN and acknowledged by the DON, who emphasized the importance of correct oxygen dosing to prevent hyperoxygenation. The facility's policy on oxygen administration was reviewed, but the deficiency in practice was evident.
A facility failed to ensure that a physician responded to a consultant pharmacist's recommendation for lab monitoring for a resident with Type 2 diabetes and major depressive disorder. Despite the pharmacist's suggestion for a Basic Metabolic Panel, there was no documented response from the physician, and the Director of Nurses confirmed the lack of communication. This deficiency highlights a failure to adhere to the facility's policy on medication regimen reviews.
A facility failed to limit PRN orders for Ativan to 14 days for a resident with anxiety, lacking a stop date or rationale for extension. The resident's order, initiated without an end date, was not evaluated by the attending physician as required by facility policy, increasing the risk of adverse effects.
A facility failed to maintain infection control by not ensuring proper PPE use and disposal in a resident's Enhanced Barrier Precautions (EBP) room. An LVN was unaware of PPE requirements during high-contact care and disposed of soiled PPE outside the resident's room, contrary to facility policy. Interviews with the DON and infection prevention nurse confirmed the importance of proper PPE use and disposal to prevent infection spread.
A resident with dementia and high fall risk experienced two unwitnessed falls shortly after admission, resulting in a head laceration. The facility failed to increase supervision or update the care plan after the first fall, and did not consistently assist with toileting. Staff interviews revealed inadequate monitoring and documentation, and the DON acknowledged the need for more frequent supervision.
A resident dependent on staff for personal hygiene and toilet use was left wet with urine for an extended period, contrary to the care plan and facility policies. The resident reported multiple instances of not receiving timely assistance after activating the call light, leading to feelings of frustration and humiliation. Interviews with staff revealed that call lights were not answered promptly, as required by facility policy.
Failure to Ensure CNA Competency in Post-Orthopedic Surgery Transfers
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) were competent in providing appropriate care and services during resident transfers for two residents who had undergone orthopedic surgery. For one resident with a recent left femur fracture and surgery, records indicated that the care plan required immobilization of the affected joints and assistance with transfers. However, during a transfer observed by a family member, two nurses twisted the resident's left leg, resulting in the resident yelling in pain and subsequently being found to have sustained a new fracture, necessitating a second surgery. The family member reported that the physical therapist had provided specific instructions for safe transfers, which were not followed by the staff involved. Another resident, admitted after joint replacement surgery, had physician orders specifying that two folded pillows should be placed under the heel while in bed and that no pillow should be placed under the knee. Despite these orders, a family member observed that nurses repeatedly placed a pillow under the resident's knee, contrary to the physician's instructions. Interviews with CNAs revealed a lack of knowledge regarding the type of surgery the resident had undergone and the necessary precautions for safe transfers. One CNA incorrectly stated that the resident's leg should be crossed during transfers, which was contradicted by the physical therapist, who emphasized the importance of keeping the legs aligned. A review of staff competency files showed that the facility had not conducted skill competencies for CNAs regarding resident transfers, particularly for those who had undergone hip or knee surgery. The Director of Staff Development confirmed that such competencies were not part of the CNA skill competency list. The facility's policies required staff to follow individualized transfer methods as identified in the care plan and to demonstrate specific competencies necessary for resident care, but these requirements were not met in practice.
Failure to Account for and Administer Medications as Ordered
Penalty
Summary
The facility failed to properly account for and administer medications as ordered by physicians for two residents. For one resident with a history of bilateral leg amputations, neuropathy, and significant pain, the facility did not account for a full delivery of Dilaudid 4 mg tablets. Pharmacy records and delivery sheets confirmed that 120 tablets were delivered in two bubble packs, but only one bubble pack and one Controlled Medication Count Sheet (CMCS) were present and accounted for. Staff interviews revealed confusion and lack of verification regarding the number of bubble packs and the corresponding CMCS, with some staff only checking the quantity upon initial receipt and not during subsequent shift counts. The Director of Nursing confirmed that staff were not consistently verifying the total quantity received and remaining, as required by facility policy, which led to a missing bubble pack and incomplete documentation. For another resident with severe cognitive impairment, dementia, and psychosis, the facility failed to administer Alprazolam 0.25 mg as ordered by the physician. The medication was given 55 minutes earlier than prescribed, and this administration was not documented in the Medication Administration Record (MAR), although it was recorded on the CMCS. The resident's care plan required anti-anxiety medications to be administered as ordered, with monitoring for side effects and effectiveness. Staff interviews and record reviews confirmed the discrepancy between the CMCS and the MAR, and the Director of Nursing acknowledged that the failure to document the administration in the MAR was a violation of facility policy. Observations and interviews with nursing staff indicated inconsistent practices in medication counting, documentation, and verification. Staff often focused on the number of medications left rather than the total quantity received, leading to discrepancies and missing medications. Facility policies required reconciliation of controlled substances upon receipt, administration, and at each shift change, but these procedures were not consistently followed. The deficiencies resulted in a lack of accountability for controlled substances and improper administration and documentation of medications.
Delayed Follow-Up on X-Ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services as ordered by the physician and as indicated in facility policy for a resident who experienced a fall and subsequently reported pain. The resident, who had a history of dementia and osteoarthritis and required assistance with daily activities, fell and later complained of ankle pain. An x-ray was ordered by the physician, and the imaging was performed the following day. However, the facility did not follow up with the radiology company to obtain the x-ray results in a timely manner. The x-ray, which revealed a nondisplaced complete transverse fracture of the medial malleolus and distal fibula, was not received by the facility until two days after it was performed. Multiple nursing staff members failed to follow up on the pending x-ray report, and there was a lack of communication and endorsement between shifts regarding the need to obtain the results. One nurse contacted the radiology company and learned of technical issues delaying report delivery but did not escalate the issue to the DON or ensure the physician was notified within the facility's required timeframe. As a result, the physician was not notified of the abnormal x-ray findings until several days after the imaging was performed, delaying the resident's transfer to the hospital for further care. The facility's policy required that changes in a resident's condition and test results be reported to the physician within 24 hours, but this standard was not met in this case.
Overflowing Trash Bin in Facility Parking Lot
Penalty
Summary
The facility failed to ensure that its trash bin was not overflowing, leading to trash being disposed of on the ground in the facility's parking lot. This was observed during a concurrent observation and interview with the Dietary Director (DD) and the Maintenance Director (MNTD). Both directors acknowledged the presence of various types of trash, including open boxes, broken containers, wooden pallets, and broken decorations, scattered on the parking lot floor within view of residents' windows. The DD and MNTD both stated that trash should be disposed of in the trash container and not on the ground, as it could potentially attract animals and bugs. During a concurrent interview and record review with the Director of Nursing (DON), the facility's policy and procedure titled 'Homelike Environment' was reviewed. The policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment, which includes a clean, sanitary, and orderly setting. The DON stated that seeing trash outside the window or scattered in the parking lot does not create a homelike environment and could make residents feel like the facility is dirty.
Failure to Label Opened Food Items
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and dating of food items, as evidenced by an observation of an open pack of ground beef in the facility's freezer without an opening date. During an interview, the Dietary Director acknowledged the absence of an opening date on the ground beef, expressing concern about not knowing how long the item had been opened, which could potentially lead to food-borne illnesses if consumed by residents. The Director of Nursing confirmed the importance of labeling opened food items to track their freshness and prevent the serving of expired or old food, which could result in health issues such as food poisoning and vomiting for the 54 residents who receive meals prepared in the facility's kitchen.
Incomplete Advance Directive Acknowledgment Form
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive Acknowledgment Form was completed upon admission. The resident, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and abnormalities of gait and mobility, did not have the capacity to understand and make decisions. Despite this, the Advance Directive Acknowledgment form was incomplete and not signed by the resident or their responsible party. During a review, the Social Services Designee confirmed that the form was not completed and acknowledged that it should have been filled out entirely to ensure that the resident's wishes were known in case of an emergency. The facility's policy indicates that residents have the right to formulate an Advance Directive, and these directives should be honored according to state law and facility policy. The failure to complete the form could lead to misinformation regarding medical care and treatment, potentially not honoring the resident's wishes when they or their responsible party are unable to make healthcare decisions.
Failure to Verify Diabetic Management Orders for Readmitted Resident
Penalty
Summary
The facility failed to ensure that Resident 53, who was readmitted from a General Acute Care Hospital (GACH), received treatment and care in accordance with professional standards of practice and the facility's policy. Resident 53, diagnosed with Type 2 diabetes mellitus, did not receive the necessary diabetic management and medications from 12/8/2024 to 1/12/2024. The facility did not verify all appropriate discharge orders from GACH 1 with the attending physician upon the resident's readmission, resulting in a lack of insulin administration and blood sugar monitoring. Upon review of Resident 53's medical records, it was found that prior to readmission, the resident was receiving insulin aspart injections according to a sliding scale for blood sugar management. However, after readmission, there were no physician orders for insulin or blood sugar checks documented in the Order Summary Report. The Director of Nursing (DON) confirmed the absence of these orders and acknowledged that the orders should have been clarified with the attending physician to ensure proper diabetic management. Interviews with the nursing staff revealed that the admitting nurse did not verify the continuation of insulin orders with the attending physician, despite the resident's history of diabetes management. The attending physician, Physician 1, stated that he expected the licensed nurse to inform him of any changes in medication orders. The facility's policy requires that physician orders for immediate care be available at the time of admission to meet the resident's care needs, which was not adhered to in this case.
Inaccurate MDS Assessment for Diabetic Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident diagnosed with diabetes mellitus, which resulted in the absence of physician orders for diabetes management. The resident, who had a history of diabetes mellitus, acute pulmonary edema, and end-stage renal disease, was readmitted to the facility without orders for insulin or blood sugar monitoring. Despite the resident's MDS indicating an active diagnosis of diabetes mellitus and the administration of insulin, the facility's records did not reflect any current orders for diabetic management. The Director of Nursing (DON) confirmed that the resident had a diagnosis of diabetes mellitus but acknowledged the lack of physician orders for insulin or blood sugar checks upon readmission. The DON stated that the purpose of clarifying orders with the physician was to ensure the resident's need for insulin was addressed. However, the DON admitted that there was a failure to clarify these orders with the physician, which could lead to uncontrolled blood sugar levels. The Minimum Data Set Nurse (MDSN) also verified that the resident had an active diagnosis of diabetes mellitus but admitted to miscoding the MDS. The MDSN explained that the MDS assessment should accurately reflect the resident's status for reimbursement purposes. The facility's policy on the accuracy of assessments emphasized the need for assessments to represent an accurate picture of the resident's status, but this was not achieved in this case.
Failure to Revise Care Plan for Diabetes Management
Penalty
Summary
The facility failed to revise the care plan for a resident diagnosed with diabetes mellitus, which resulted in the absence of physician orders for diabetes management. The resident, who had a history of diabetes mellitus, acute pulmonary edema, and end-stage renal disease, was readmitted to the facility without orders for insulin or blood sugar checks. Despite having an active care plan for diabetes management, the care plan was not updated to reflect the current physician orders, leading to a potential gap in the resident's diabetes treatment. The resident's medical records indicated that prior to readmission, insulin was administered according to a sliding scale. However, upon readmission, the Order Summary Report did not include any orders for insulin or blood sugar monitoring. The Director of Nursing (DON) confirmed the absence of these orders and acknowledged the need for clarification with the physician to ensure proper diabetes management. The facility's policy requires that care plans be revised when a resident is readmitted from a hospital stay. However, the Minimum Data Set Nurse (MDSN) verified that the care plan did not reflect the current physician orders, emphasizing the importance of updating the care plan to guide staff in managing the resident's diabetes. This oversight in revising the care plan could lead to the resident not receiving appropriate treatment for diabetes management.
Failure to Conduct Comprehensive Nutritional Assessment for Diabetic Resident
Penalty
Summary
The facility failed to ensure a comprehensive nutritional assessment for a resident diagnosed with diabetes mellitus, which could potentially result in the resident not receiving the appropriate diet and nutritional needs. The resident, who had a history of diabetes mellitus, was readmitted to the facility without a proper assessment of her dietary needs related to her condition. The facility's records indicated that the resident had been receiving insulin as per a sliding scale prior to her readmission, but upon her return, there were no orders for insulin or blood sugar checks. The Director of Nursing (DON) confirmed that there were no physician orders for diabetic management upon the resident's readmission, which could lead to uncontrolled blood sugar levels. The DON acknowledged that the orders should have been clarified with the physician to ensure the resident's diabetes was managed appropriately. Additionally, the Consultant Dietitian (CD) admitted to missing the resident's diabetes diagnosis during the nutritional assessment, resulting in an incorrect diet being prescribed. The facility's policy required a nutritional assessment to be conducted by a multidisciplinary team, identifying clinical conditions and risk factors affecting the resident's nutritional status. However, the oversight in recognizing the resident's diabetes diagnosis and the lack of appropriate dietary orders demonstrated a failure in adhering to this policy. This deficiency highlights the need for accurate and comprehensive assessments to ensure residents receive the necessary care for their medical conditions.
Oxygen Flow Rate Mismanagement for Resident with Chronic Respiratory Failure
Penalty
Summary
The facility failed to ensure that a resident with chronic respiratory failure was receiving the appropriate oxygen flow rate as ordered by the attending physician. The resident, who was admitted with diagnoses including chronic respiratory failure and pulmonary embolism, had a physician order to receive oxygen at 2 to 4 liters per minute (LPM) via nasal cannula continuously. However, during an observation, it was noted that the resident's oxygen machine was set at 4.5 LPM, exceeding the prescribed range. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the oxygen setting was not in accordance with the physician's order. The resident's care plan and medication administration record both indicated the need for oxygen therapy at the specified rate, yet the facility's failure to adhere to this order posed a risk of hyperoxygenation. The Director of Nursing (DON) confirmed the importance of administering the correct oxygen dose to prevent potential adverse effects such as hyperoxygenation, which could lead to seizures and injury. The facility's policy on oxygen administration was reviewed, highlighting the need for proper oxygen flow adjustment, but the deficiency in practice was evident in the observed deviation from the prescribed oxygen flow rate.
Failure to Communicate Pharmacist's Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician responded to a recommendation made by the consultant pharmacist regarding laboratory monitoring for a resident. The resident, who was admitted and readmitted to the facility with diagnoses including Type 2 diabetes mellitus and major depressive disorder, had the capacity to understand and make decisions. The consultant pharmacist conducted a medication regimen review and recommended that the resident's primary physician clarify if it was clinically appropriate to perform a Basic Metabolic Panel (BMP) lab test. However, there was no documented response from the attending physician to this recommendation. The Director of Nurses confirmed during an interview that there was no documentation indicating that the facility had informed the resident's physician of the consultant pharmacist's recommendation. The facility's policy on medication regimen reviews, revised in August 2019, states that findings and recommendations should be reported to the director of nursing and the attending physician. The lack of communication and documentation regarding the pharmacist's recommendation represents a deficiency in the facility's adherence to its own policies and procedures.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that PRN orders for the psychotropic medication Ativan were limited to a duration of 14 days and evaluated for continued use for a resident taking psychotropic medications. The resident's physician order for Ativan, which was initiated on 12/17/2024, did not include a stop date. This oversight was identified during a review of the resident's Order Summary Report dated 1/11/2025, which indicated the medication was prescribed to be taken as needed for anxiety-related symptoms without a specified end date. During an interview and concurrent record review with the Director of Nursing (DON), it was confirmed that the Ativan order did not include a stop date or a rationale for extending the medication beyond the 14-day limit. The facility's policy requires that PRN psychotropic medications be renewed every 14 days and evaluated by the resident's attending physician before renewal. The lack of adherence to this policy increased the risk of adverse effects for the resident, who had a history of hemiplegia, hemiparesis, and type 2 diabetes mellitus.
Inadequate PPE Use and Disposal in EBP Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections, as observed in the case of a resident with Enhanced Barrier Precautions (EBP) due to a gastrostomy tube. The Licensed Vocational Nurse (LVN) responsible for the resident was not fully aware of the requirements for wearing personal protective equipment (PPE) during high-contact care activities, such as using the feeding tube. During a medication administration observation, the LVN initially did not have access to an isolation cart with PPE at the entrance of the resident's room and had to find an isolation gown elsewhere. This indicates a lack of proper PPE availability and awareness of EBP protocols. Additionally, the LVN improperly disposed of the soiled PPE by exiting the resident's room and discarding the gown in a soiled linen bin across the hall, rather than in a disposal bin inside the resident's room. This action was contrary to the facility's policy, which required PPE to be disposed of inside the resident's room to prevent the spread of infection. Interviews with the Director of Nursing and the infection prevention nurse confirmed the importance of wearing PPE during high-risk activities and disposing of it properly to protect both staff and residents. The facility's policy and signage also emphasized these practices, highlighting the deficiency in adherence to infection control protocols.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to a resident with dementia, Guillain-Barre syndrome, and a high risk for falls. The resident experienced two unwitnessed falls shortly after admission, resulting in a laceration to the back of the head that required medical attention. The facility did not increase the resident's supervision needs or develop an individualized care plan after the first fall, as required by their policy. The facility also failed to implement the resident's care plan for monitoring and frequent visual checks after the initial fall. The staff did not analyze the risk or identify trends in the resident's fall incidents, which were associated with frequent attempts to get out of bed and an inability to void. The resident required assistance with toileting, but this was not consistently provided, contributing to the falls. Interviews with staff revealed that the facility did not have a system in place to indicate the frequency of monitoring, and documentation of the resident's whereabouts was insufficient. The Director of Nursing acknowledged that the care plan was not updated to reflect the resident's continuous fall risk, and additional interventions such as one-to-one supervision were not implemented, which could have potentially prevented the second fall.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident's ability to perform activities of daily living (ADL) did not diminish. The resident, who was dependent on staff for personal hygiene and toilet use, was left wet with urine for an extended period, contrary to the care plan and facility policies. The resident, who had no cognitive impairment and was at risk for skin breakdown due to incontinence, reported multiple instances of not receiving timely assistance after activating the call light. The resident expressed feelings of frustration and humiliation due to being left in a wet diaper. Interviews with facility staff revealed that the call lights were not answered promptly, as required by the facility's policy. The Interim Director of Nursing acknowledged the incident, stating that the CNA was busy with another resident at the time. The Director of Staff Development emphasized the importance of answering call lights immediately, as delays could pose life-threatening risks. A CNA confirmed finding the resident wet and frustrated, with urine on the floor, after the call light had been activated multiple times without response.
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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) |
|---|---|---|---|---|
| Pico Rivera Healthcare Center | 1.4 mi | — | 21 | 0 |
| El Rancho Vista Health Care Center | 1.4 mi | — | 23 | 0 |
| Presbyterian Intercomm Hosp Dp/snf | 1.5 mi | — | 0 | 0 |
| The Orchard - Post Acute Care | 1.5 mi | — | 3 | 0 |
| Colonial Gardens Nursing Home | 1.7 mi | — | 13 | 0 |
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